Provider Demographics
NPI:1548356934
Name:CHAN AMIGO, NANCY LEE (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEE
Last Name:CHAN AMIGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8375 WOODHAVEN BLVD
Mailing Address - Street 2:LOBBY#14
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8375 WOODHAVEN BLVD
Practice Address - Street 2:LOBBY#14
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1535
Practice Address - Country:US
Practice Address - Phone:718-849-5012
Practice Address - Fax:718-805-2422
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY144564208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00765953Medicaid
NY00765953Medicaid