Healthcare Provider Details

I. General information

NPI: 1538370903
Provider Name (Legal Business Name): NANCY ANNE PANSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MOUNTAIN AVE SUITE A104
UPLAND CA
91786-4331
US

IV. Provider business mailing address

12729 GEORGE CT
ETIWANDA CA
91739-1682
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-1033
  • Fax: 909-981-8976
Mailing address:
  • Phone: 909-463-1233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 15642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: