Provider Demographics
NPI:1679127872
Name:PAN, JACQUELINE (OD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 BOUGAINVILLE DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3179
Mailing Address - Country:US
Mailing Address - Phone:808-312-3878
Mailing Address - Fax:
Practice Address - Street 1:4725 BOUGAINVILLE DR
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3179
Practice Address - Country:US
Practice Address - Phone:808-312-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-1043152W00000X
PAOEG003595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist