Healthcare Provider Details

I. General information

NPI: 1043409105
Provider Name (Legal Business Name): GRACE PANGANIBAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 57TH ST SUITE 1406
NEW YORK NY
10019-2802
US

IV. Provider business mailing address

57 W 57TH ST # W SUITE 1406
NEW YORK NY
10019-2802
US

V. Phone/Fax

Practice location:
  • Phone: 212-399-3800
  • Fax: 212-399-3822
Mailing address:
  • Phone: 212-399-3800
  • Fax: 212-399-3822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number028949
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: