Provider Demographics
NPI:1629333471
Name:PANNU, PRINCE (MD)
Entity Type:Individual
Prefix:DR
First Name:PRINCE
Middle Name:
Last Name:PANNU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-738-2200
Mailing Address - Fax:360-752-5687
Practice Address - Street 1:4545 CORDATA PKWY
Practice Address - Street 2:SUITE 2C
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7263
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5687
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL12295207Q00000X
WAMD60535103207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine