Provider Demographics
NPI:1972113074
Name:PAN, JOSHUA (PA-C)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2200 OPITZ BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3342
Mailing Address - Country:US
Mailing Address - Phone:703-492-4140
Mailing Address - Fax:571-291-2338
Practice Address - Street 1:2200 OPITZ BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3342
Practice Address - Country:US
Practice Address - Phone:703-492-4140
Practice Address - Fax:571-291-2338
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031832363A00000X
VA0110007362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant