Provider Demographics
NPI:1225244817
Name:BANOGON, JOHN JAMES ENCARNACION (PT, DPT, GCS, CWS)
Entity Type:Individual
Prefix:
First Name:JOHN JAMES
Middle Name:ENCARNACION
Last Name:BANOGON
Suffix:
Gender:M
Credentials:PT, DPT, GCS, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 OLD PASCACK RD
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-1531
Mailing Address - Country:US
Mailing Address - Phone:914-661-2776
Mailing Address - Fax:
Practice Address - Street 1:76 OLD PASCACK RD
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-1531
Practice Address - Country:US
Practice Address - Phone:914-661-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00782700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist