Provider Demographics
NPI:1053023010
Name:CHAN, DAVID WAI (MSN, AGPCNP-BC, RN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WAI
Last Name:CHAN
Suffix:
Gender:M
Credentials:MSN, AGPCNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GILMORE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1721
Mailing Address - Country:US
Mailing Address - Phone:413-441-3986
Mailing Address - Fax:
Practice Address - Street 1:243 CHARLES ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3002
Practice Address - Country:US
Practice Address - Phone:617-523-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN216147363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology