Provider Demographics
NPI:1790123925
Name:PAN, ADRIENNE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:MARIE
Last Name:PAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL09502084N0008X
NVDO20892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine