Provider Demographics
NPI:1255403994
Name:PAN, JEANNE P
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:P
Last Name:PAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:P0-HUI
Other - Last Name:PAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:29600 ISLAND VIEW DR
Mailing Address - Street 2:#105
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4650
Mailing Address - Country:US
Mailing Address - Phone:626-297-0643
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:626-851-7037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15140NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMH1406809OtherDEA NUMBER
CAQ44429Medicare UPIN