Basic Information
Provider Information | |||||||||
NPI: | 1568819308 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAN | ||||||||
FirstName: | YUJUN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 MEDICAL CENTER DR DEPT OF | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037561000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036505000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037561000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036505000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2016 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 2016015535 | MO | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0101X | 22392 | NH | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
ID | Type | State | Issuer | Description | 2016015535 | 01 | MO | MO LICENSE | OTHER |