Basic Information
| Provider Information | |||||||||
| NPI: | 1043233810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | FAI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 51 NORTHTOWN DR | ||||||||
| Address2: | 19E | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392113600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103624471 | ||||||||
| FaxNumber: | 6013641588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | RADIATION THERAPY | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
| FaxNumber: | 6013641588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | A60276 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 18104 | MS | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.