Provider Demographics
NPI:1336929488
Name:PAN, BOL GACH
Entity Type:Individual
Prefix:
First Name:BOL
Middle Name:GACH
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 1:8050 N 19TH AVE # 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5101
Mailing Address - Country:US
Mailing Address - Phone:602-481-0911
Mailing Address - Fax:
Practice Address - Street 1:9250 N 75TH AVE LOT 48
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6634
Practice Address - Country:US
Practice Address - Phone:602-481-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD06464178343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)