Healthcare Provider Details

I. General information

NPI: 1225949480
Provider Name (Legal Business Name): JIALIANG PAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 UNION ST STE 6D
FLUSHING NY
11354-5672
US

IV. Provider business mailing address

4720 170TH ST
FLUSHING NY
11358-3720
US

V. Phone/Fax

Practice location:
  • Phone: 718-463-3838
  • Fax:
Mailing address:
  • Phone: 646-327-7632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF358766-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: