Provider Demographics
NPI:1750721049
Name:PAN, VIVIAN (CGC)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:PAN
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 N WESTERN AVE APT 4A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6933
Mailing Address - Country:US
Mailing Address - Phone:312-952-2584
Mailing Address - Fax:312-996-5760
Practice Address - Street 1:818 S WOLCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3702
Practice Address - Country:US
Practice Address - Phone:312-413-4478
Practice Address - Fax:312-996-5760
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000062A170300000X
IL247000040170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS