Healthcare Provider Details

I. General information

NPI: 1629993860
Provider Name (Legal Business Name): ISAIAH PANTOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W BROADWAY AVE
MINNEAPOLIS MN
55411-2407
US

IV. Provider business mailing address

1505 W BROADWAY AVE
MINNEAPOLIS MN
55411-2407
US

V. Phone/Fax

Practice location:
  • Phone: 952-463-7716
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: