Provider Demographics
NPI:1043623622
Name:PANGANDAMAN, ANNISAH
Entity Type:Individual
Prefix:
First Name:ANNISAH
Middle Name:
Last Name:PANGANDAMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SAWGRASS CORPORATE PKWY,MEDPRO HEALTHCARRE STAFFIN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323
Mailing Address - Country:US
Mailing Address - Phone:954-332-4445
Mailing Address - Fax:
Practice Address - Street 1:1580 SAWGRASS CORPORATE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323
Practice Address - Country:US
Practice Address - Phone:954-332-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036530225100000X
IL070.020398225100000X
NM4455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist