Healthcare Provider Details

I. General information

NPI: 1326801234
Provider Name (Legal Business Name): SERGEI PANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N HOCKETT ST,
PORTERVILLE CA
93257
US

IV. Provider business mailing address

210 WOODHAVEN LN
MANKATO MN
56001-5706
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 925-567-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: