Provider Demographics
NPI:1417538315
Name:PANTEAH, MYLAN DANIEL
Entity Type:Individual
Prefix:
First Name:MYLAN
Middle Name:DANIEL
Last Name:PANTEAH
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 1:4207 KITSAP WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-2447
Mailing Address - Country:US
Mailing Address - Phone:360-415-1080
Mailing Address - Fax:360-415-1099
Practice Address - Street 1:4207 KITSAP WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2447
Practice Address - Country:US
Practice Address - Phone:360-415-1080
Practice Address - Fax:360-415-1099
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty