Basic Information
| Provider Information | |||||||||
| NPI: | 1508521147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | BONNIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3319 191ST ST | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113581939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186837979 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2021 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 344975 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.