Basic Information
| Provider Information | |||||||||
| NPI: | 1588634331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | CHRISTIANA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11781 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5717775102 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 5950 SR6 | ||||||||
| Address2: | |||||||||
| City: | TUNKHANNOCK, | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708362161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | OS009565L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001668739 0006 | 05 | PA | MEDICAID | 0016687390007 | 05 | PA | MEDICAID | P00393423 | 01 | RR MEDICARE | OTHER |