Provider Demographics
NPI:1194356121
Name:PANCIC, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:PANCIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 N HUNTER CT
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158-1048
Mailing Address - Country:US
Mailing Address - Phone:816-309-8189
Mailing Address - Fax:
Practice Address - Street 1:10841 W 87TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-1660
Practice Address - Country:US
Practice Address - Phone:913-825-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSTHR-0655677225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist