Basic Information
| Provider Information | |||||||||
| NPI: | 1942231899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | Y. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980554934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24920 104TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980306443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903420 | ||||||||
| FaxNumber: | 4256909420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00035212 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | MD00035212 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8230914 | 05 | WA | MEDICAID | 1022726 | 05 | WA | MEDICAID |