Healthcare Provider Details

I. General information

NPI: 1558587519
Provider Name (Legal Business Name): ANDREA LOUISE PANA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 ROBERT DEDMAN DRIVE MNC 1.218
AUSTIN TX
78712
US

IV. Provider business mailing address

360 NUECES ST #1105
AUSTIN TX
78701-4195
US

V. Phone/Fax

Practice location:
  • Phone: 512-471-5513
  • Fax:
Mailing address:
  • Phone: 512-203-8940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM1285
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG74916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: