1760550420 NPI number — DR. JENNY S PAN MD

Table of content: DR. JENNY S PAN MD (NPI 1760550420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760550420 NPI number — DR. JENNY S PAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAN
Provider First Name:
JENNY
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHEN PAN
Provider Other First Name:
SHEUE
Provider Other Middle Name:
CHING
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760550420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4673 CANDLEBERRY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEAL BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90740-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-345-8729
Provider Business Mailing Address Fax Number:
714-540-0311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
SUITE 605
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90813-3408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-901-6767
Provider Business Practice Location Address Fax Number:
562-901-6777
Provider Enumeration Date:
12/01/2006

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: 208000000X , with the licence number:  A43079 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080N0001X , with the licence number: A43079 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00A430790 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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