Basic Information
Provider Information
NPI: 1124418934
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PANGANIBAN
FirstName: KENNETH
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10270 STALLION RUN COURT
Address2:  
City: JACKSONVILLE
State: FL
PostalCode: 32257
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 232 PONTE VEDRA PARK DR
Address2:  
City: PONTE VEDRA BEACH
State: FL
PostalCode: 320826600
CountryCode: US
TelephoneNumber: 9046340640
FaxNumber: 9046340203
Other Information
ProviderEnumerationDate: 02/01/2015
LastUpdateDate: 08/11/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA59111FLN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 
225200000XPTA25367FLY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


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