Provider Demographics
NPI:1861629248
Name:PANICHPAKDEE, TANYA (DPM)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:PANICHPAKDEE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 CALLE MARSEILLE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-3219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:357 CALLE MARSEILLE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-3219
Practice Address - Country:US
Practice Address - Phone:562-852-8510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5013213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHG815AMedicare PIN
CA6871740001Medicare NSC