Provider Demographics
NPI:1326263609
Name:PANASUK, ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:PANASUK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 RAEBURN CT
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-9796
Mailing Address - Country:US
Mailing Address - Phone:360-437-5128
Mailing Address - Fax:
Practice Address - Street 1:30 RAEBURN CT
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-9796
Practice Address - Country:US
Practice Address - Phone:360-437-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1173TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist