Basic Information
| Provider Information | |||||||||
| NPI: | 1659900546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | ELROY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 504 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123052414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 309580 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.