Basic Information
Provider Information | |||||||||
NPI: | 1215946496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAN | ||||||||
FirstName: | AUDREY | ||||||||
MiddleName: | Y. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3160 FOLSOM BLVD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958165219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167333440 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3160 FOLSOM BLVD | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958165219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167335336 | ||||||||
FaxNumber: | 9167335385 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 09/24/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A8667 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00AX86670 | 05 | CA |   | MEDICAID | 000810568272 | 01 | CA | PHCS | OTHER | 102632 | 01 | CA | HEALTH NET | OTHER | 2358909 | 01 | CA | UNITED HEALTHCARE | OTHER | 90136584 | 01 | CA | PACIFICARE | OTHER | 20A8667 | 01 | CA | BLUE CROSS | OTHER | 2149412 | 01 | CA | FIRST HEALTH | OTHER | 7810479 | 01 | CA | AETNA | OTHER | 5013958 | 01 | CA | CIGNA | OTHER | 1708821 | 01 | CA | GREAT WEST | OTHER | 99081 | 01 | CA | INTERPLAN | OTHER | MCMG274500 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER |