1609003961 NPI number — CHUAN-JU GWENDOLYN PAN M.D.

Table of content: CHUAN-JU GWENDOLYN PAN M.D. (NPI 1609003961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609003961 NPI number — CHUAN-JU GWENDOLYN PAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAN
Provider First Name:
CHUAN-JU
Provider Middle Name:
GWENDOLYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609003961
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 W LA VETA AVE
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-541-6622
Provider Business Mailing Address Fax Number:
714-541-0531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 W LA VETA AVE
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-541-6622
Provider Business Practice Location Address Fax Number:
714-541-0531
Provider Enumeration Date:
06/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  A110998 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W12156 . This is a "PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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