Healthcare Provider Details

I. General information

NPI: 1528310075
Provider Name (Legal Business Name): NINO PAGAPULAAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551D BALTIMORE ANNAPOLIS BLVD
SEVERNA PARK MD
21146-3809
US

IV. Provider business mailing address

PO BOX 4058
CROFTON MD
21114-4058
US

V. Phone/Fax

Practice location:
  • Phone: 410-315-9080
  • Fax: 410-315-9012
Mailing address:
  • Phone: 301-262-5852
  • Fax: 301-262-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22418
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: