Provider Demographics
NPI:1972199073
Name:PAN, WANG
Entity Type:Individual
Prefix:
First Name:WANG
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 PASADENA AVE STE 10C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-6142
Mailing Address - Country:US
Mailing Address - Phone:626-219-9258
Mailing Address - Fax:
Practice Address - Street 1:99 PASADENA AVE STE 10C
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-6142
Practice Address - Country:US
Practice Address - Phone:323-341-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-22-60108103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst