Provider Demographics
NPI:1154531507
Name:PANGANIBAN, MADELAINE
Entity type:Individual
Prefix:MISS
First Name:MADELAINE
Middle Name:
Last Name:PANGANIBAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12938 SYCAMORE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-8333
Mailing Address - Country:US
Mailing Address - Phone:714-225-5001
Mailing Address - Fax:
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-932-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13679363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily