Healthcare Provider Details

I. General information

NPI: 1588646178
Provider Name (Legal Business Name): HERNANI PANTINOPLE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 1 BOX 110 ROUTE209
BRODHEADSVILLE PA
18322-9532
US

IV. Provider business mailing address

223 BLUE MOUNTAIN LK
EAST STROUDSBURG PA
18301-8691
US

V. Phone/Fax

Practice location:
  • Phone: 570-992-4400
  • Fax: 570-992-5262
Mailing address:
  • Phone: 201-281-3619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT011887L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: