Provider Demographics
NPI:1902174899
Name:PANGAN, JON RUDOLF (INDEPENDENT DUTY HM)
Entity type:Individual
Prefix:
First Name:JON RUDOLF
Middle Name:
Last Name:PANGAN
Suffix:
Gender:M
Credentials:INDEPENDENT DUTY HM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 BONNEY RD
Mailing Address - Street 2:APARTMENT 206
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3889
Mailing Address - Country:US
Mailing Address - Phone:619-847-5977
Mailing Address - Fax:
Practice Address - Street 1:4432 BONNEY RD
Practice Address - Street 2:APARTMENT 206
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3889
Practice Address - Country:US
Practice Address - Phone:619-847-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman