Provider Demographics
NPI:1326624016
Name:PANOS, PATRICK THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:THOMAS
Last Name:PANOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 S MAPLE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-7332
Mailing Address - Country:US
Mailing Address - Phone:801-671-5226
Mailing Address - Fax:
Practice Address - Street 1:11820 S MAPLE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-7332
Practice Address - Country:US
Practice Address - Phone:801-671-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116155-2501103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT116155-2501OtherSTATE OF UTAH- PSYCHOLOGY LICENSE NUMBER
UT116155-2501OtherSTATE OF UTAH: PSYCHOLOGY LICENSE