=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588646178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HERNANI PANTINOPLE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HC 1 BOX 110 ROUTE209
-----------------------------------------------------
City | BRODHEADSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18322-9532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-992-4400
-----------------------------------------------------
Fax | 570-992-5262
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 BLUE MOUNTAIN LK
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-8691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-281-3619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT011887L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------