Provider Demographics
NPI:1275955320
Name:PANGANIBAN, VINCENT PAULO FORMALEJO (PT)
Entity Type:Individual
Prefix:
First Name:VINCENT PAULO
Middle Name:FORMALEJO
Last Name:PANGANIBAN
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 1:6420 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-7111
Mailing Address - Country:US
Mailing Address - Phone:503-864-5343
Mailing Address - Fax:
Practice Address - Street 1:6420 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-7111
Practice Address - Country:US
Practice Address - Phone:503-864-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist