Healthcare Provider Details

I. General information

NPI: 1427883115
Provider Name (Legal Business Name): JAMMIL PAGADUAN WATAN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E ORANGEBURG AVE STE 330
MODESTO CA
95355-3396
US

IV. Provider business mailing address

1160 PROVIDENCE CT
TRACY CA
95376-9389
US

V. Phone/Fax

Practice location:
  • Phone: 209-724-6000
  • Fax:
Mailing address:
  • Phone: 510-512-4498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number306661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: