=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639844681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC MEDICAL DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2021
-----------------------------------------------------
Last Update Date | 08/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1888 KALAKAUA AVE STE C104
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-205-7266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1888 KALAKAUA AVE STE C104
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | PATRICK PAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-205-7266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------