Provider Demographics
NPI:1730808791
Name:CHAN, BRENDON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:BRENDON
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SUMMIT POINTE WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4034
Mailing Address - Country:US
Mailing Address - Phone:917-837-9212
Mailing Address - Fax:
Practice Address - Street 1:4450 HUGH HOWELL RD STE 17
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4726
Practice Address - Country:US
Practice Address - Phone:770-939-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist