Provider Demographics
NPI:1528298874
Name:AHN, CHISHIN
Entity type:Individual
Prefix:
First Name:CHISHIN
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5110
Mailing Address - Country:US
Mailing Address - Phone:805-614-5070
Mailing Address - Fax:805-614-5072
Practice Address - Street 1:615 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5110
Practice Address - Country:US
Practice Address - Phone:805-614-5070
Practice Address - Fax:805-614-5072
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10212171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0102120Medicaid