Provider Demographics
NPI:1447770680
Name:PAN, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:15816 79TH AVE APT N307
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1098
Mailing Address - Country:US
Mailing Address - Phone:516-459-1342
Mailing Address - Fax:
Practice Address - Street 1:13503B ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5305
Practice Address - Country:US
Practice Address - Phone:718-961-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist