Provider Demographics
NPI:1972525202
Name:PAN, PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 TROY RD
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-4725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2210 TROY RD
Practice Address - Street 2:
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-4725
Practice Address - Country:US
Practice Address - Phone:518-346-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2337542080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02611549Medicaid
NYRA5564Medicare ID - Type Unspecified
NYI24450Medicare UPIN