Provider Demographics
NPI:1215946496
Name:PAN, AUDREY Y (DO)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:Y
Last Name:PAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 FOLSOM BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5219
Mailing Address - Country:US
Mailing Address - Phone:916-733-3440
Mailing Address - Fax:
Practice Address - Street 1:3160 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5219
Practice Address - Country:US
Practice Address - Phone:916-733-5336
Practice Address - Fax:916-733-5385
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX86670Medicaid
CA000810568272OtherPHCS
CA102632OtherHEALTH NET
CA2358909OtherUNITED HEALTHCARE
CA90136584OtherPACIFICARE
CA20A8667OtherBLUE CROSS
CA2149412OtherFIRST HEALTH
CA7810479OtherAETNA
CA5013958OtherCIGNA
CA1708821OtherGREAT WEST
CA99081OtherINTERPLAN
CAMCMG274500OtherWESTERN HEALTH ADVANTAGE
CA99081OtherINTERPLAN
CA00AX86670Medicaid