Provider Demographics
NPI:1700626652
Name:CHAN, MICKEY DE GUZMAN (DMSC, MHSC, PA-C)
Entity type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:DE GUZMAN
Last Name:CHAN
Suffix:
Gender:M
Credentials:DMSC, MHSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 COLORADO AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-2709
Mailing Address - Country:US
Mailing Address - Phone:209-226-4299
Mailing Address - Fax:
Practice Address - Street 1:1801 COLORADO AVE STE 160
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2709
Practice Address - Country:US
Practice Address - Phone:209-226-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65304363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA65304OtherCA PA LICENSE