Provider Demographics
NPI:1093373524
Name:BANTUGAN, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:BANTUGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 STEFANI RD
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-7795
Mailing Address - Country:US
Mailing Address - Phone:850-607-6910
Mailing Address - Fax:850-607-6932
Practice Address - Street 1:6800 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-8969
Practice Address - Country:US
Practice Address - Phone:850-607-6910
Practice Address - Fax:850-607-6932
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-88330106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician