Provider Demographics
NPI:1760550420
Name:PAN, JENNY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:S
Last Name:PAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:SHEUE
Other - Middle Name:CHING
Other - Last Name:CHEN PAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4673 CANDLEBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-3033
Mailing Address - Country:US
Mailing Address - Phone:714-345-8729
Mailing Address - Fax:714-540-0311
Practice Address - Street 1:1045 ATLANTIC AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3408
Practice Address - Country:US
Practice Address - Phone:562-901-6767
Practice Address - Fax:562-901-6777
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43079208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A430790Medicaid