Provider Demographics
NPI:1962065979
Name:CHAN, COREY (PA-C)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
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 1:550 LYNN ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-602-2945
Mailing Address - Fax:
Practice Address - Street 1:550 LYNN ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-602-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026226363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant