=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245394949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN OKLAHOMA ENT, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 W 3RD ST SUITE 102
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-225-5365
-----------------------------------------------------
Fax | 580-225-2174
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 W 3RD ST SUITE 102
-----------------------------------------------------
City | ELK CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73644-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-225-5365
-----------------------------------------------------
Fax | 580-225-2174
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER
-----------------------------------------------------
Name | CHENG H PAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 580-225-5365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 24331
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------