Basic Information
| Provider Information | |||||||||
| NPI: | 1568091619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANCHUAN | ||||||||
| FirstName: | MAYSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1847 WINONA BLVD APT 307 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900273880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184058765 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900731003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2020 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 780355 | CA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | NP95013244 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.