Provider Demographics
NPI:1588904866
Name:CHAN, JESSIE K (PA)
Entity type:Individual
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First Name:JESSIE
Middle Name:K
Last Name:CHAN
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Gender:F
Credentials:PA
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Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:STE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:400 W FAIRBANKS AVE
Practice Address - Street 2:STE E
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5084
Practice Address - Country:US
Practice Address - Phone:407-645-2300
Practice Address - Fax:407-645-2308
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2013-06-28
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Provider Licenses
StateLicense IDTaxonomies
FLPA9106851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHA137YMedicare PIN