Provider Demographics
NPI:1578232534
Name:FAN, LUCINDA (PA-C)
Entity type:Individual
Prefix:
First Name:LUCINDA
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N VEITCH ST UNIT 1406
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-6208
Mailing Address - Country:US
Mailing Address - Phone:909-837-7936
Mailing Address - Fax:
Practice Address - Street 1:4060 FOURTH AVE STE 240
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2120
Practice Address - Country:US
Practice Address - Phone:619-291-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59936363A00000X
VA0110008048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant