Provider Demographics
NPI:1003080524
Name:PAN, QIUPING A
Entity Type:Individual
Prefix:
First Name:QIUPING
Middle Name:A
Last Name:PAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 FLOWERS RD S APT V
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5680
Mailing Address - Country:US
Mailing Address - Phone:770-457-6043
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERAN BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine