Provider Demographics
NPI:1972891810
Name:PAN, DIANA (OD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SOUTHCENTER MALL
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2810
Mailing Address - Country:US
Mailing Address - Phone:206-243-2322
Mailing Address - Fax:206-209-0002
Practice Address - Street 1:301 SOUTHCENTER MALL
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2810
Practice Address - Country:US
Practice Address - Phone:206-243-2322
Practice Address - Fax:206-209-0002
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60383458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist