Provider Demographics
NPI:1053668947
Name:INCIONG, ROGER CABO (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:CABO
Last Name:INCIONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 RAPALLO WAY
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337
Mailing Address - Country:US
Mailing Address - Phone:408-656-9834
Mailing Address - Fax:
Practice Address - Street 1:3652 RAPALLO WAY
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337
Practice Address - Country:US
Practice Address - Phone:408-656-9834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39037225100000X
GAPT010352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist