Provider Demographics
NPI:1992099337
Name:CHAN, DIANNE FONG (PTA)
Entity type:Individual
Prefix:MISS
First Name:DIANNE
Middle Name:FONG
Last Name:CHAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 CROCUS DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3811
Mailing Address - Country:US
Mailing Address - Phone:510-326-6696
Mailing Address - Fax:
Practice Address - Street 1:2481 CREEKSIDE CT
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-2359
Practice Address - Country:US
Practice Address - Phone:510-326-6696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant