Provider Demographics
NPI:1093798043
Name:IMBROGNO, PAUL L (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
Last Name:IMBROGNO
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 1:911 LIGONIER ST
Mailing Address - Street 2:SUITE 001
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1805
Mailing Address - Country:US
Mailing Address - Phone:724-537-9577
Mailing Address - Fax:724-537-0195
Practice Address - Street 1:5840 ROUTE 981
Practice Address - Street 2:SUITE 103
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-5385
Practice Address - Country:US
Practice Address - Phone:724-539-6667
Practice Address - Fax:724-539-6614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT000761E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396560Medicare ID - Type UnspecifiedREHABILITATION AGENCY/OPT