Fairway Children'S Medical Group
Organization Active NPI Pediatrics Physician · West Covina, CA
NPI 1700510898 · NPPES record last updated Apr 23, 2025
Key facts
- NPI
- 1700510898
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- Legal business name
- FAIRWAY CHILDREN'S MEDICAL GROUP
- Practice address
- 2707 E Valley Blvd Ste 215
West Covina, CA 91792-3197 - Phone
- (909) 594-3382
- Fax
- (626) 667-7633
- NPI assigned
- Jul 13, 2022
- Organization subpart
- No
Authorized official
- Name
- Jackyln Chan, MD
- Title
- Owner
- Phone
- (909) 630-8762
Practitioners 8
-
Jackyln Wai-Shan Chan, M.D.
-
Tiffany Thanh Nguyen, MD, MS
-
Jessica Wang, FNP-C
-
Monica Avila, NP
-
Elsa Ann Castanon Quintana, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0720261 | Fairway Children'S Medical Group Laboratory | Certificate of waiver | Aug 31, 2026 |
| 05D2305139 | Fairway Children'S Medical Group Laboratory | Certificate of waiver | May 23, 2028 |
National Provider Directory
Locations
888 Brea Canyon Rd
Ste 330
Diamond Bar, CA 91789
Phone (909) 594-3382
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | Yes |
Addresses
Primary practice location
2707 E Valley Blvd Ste 215
West Covina, CA 91792-3197
Mailing address
888 Brea Canyon Rd Ste 330
Diamond Bar, CA 91789-3095
Phone (909) 594-3382
Other practice location 1
888 Brea Canyon Rd Ste 330
Diamond Bar, CA 91789-3095
Phone (909) 594-3382
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1447544333 | Other | CA | INDIVIDUAL TYPE 1 NPI |
| A130711 | Other | CA | CA MD STATE LICENSE # |
Other providers in West Covina, CA
- Moses Ewo
- Excel Imaging Center West Covina Inc.
- Eyehome Network of California, an Optometric Corporation
- Eyexam of California
- Anthony Curtis Ezedi
- Natalia Isabel Fajardo
- David Falcon-Valentin
- Raymon Joe Falcon
- Family Associated Medical Group Inc.
- Family Care Transportation,Inc.
All providers in West Covina, CA · Pediatrics Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 23, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.