Provider Demographics
NPI:1699134098
Name:CHAN, ADRIENNE CAROL MAR (PA-C)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:CAROL MAR
Last Name:CHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 EAST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:323-268-8391
Mailing Address - Fax:858-633-4702
Practice Address - Street 1:1625 EAST 4TH STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-268-8391
Practice Address - Fax:858-633-4702
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101049183700000X
CA53152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183700000XPharmacy Service ProvidersPharmacy Technician