Provider Demographics
NPI:1679644181
Name:PANG, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8047
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91224-0047
Mailing Address - Country:US
Mailing Address - Phone:949-770-1122
Mailing Address - Fax:949-770-9189
Practice Address - Street 1:24712 CLARINGTON DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4305
Practice Address - Country:US
Practice Address - Phone:949-770-1122
Practice Address - Fax:949-770-9189
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69884207RN0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A698840Medicaid
CA00A698840Medicaid