Provider Demographics
NPI:1336479955
Name:PANTINO JR, ALFREDO BESAVILLA
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:BESAVILLA
Last Name:PANTINO JR
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 1:15533 JOHN DISKIN CIR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6378
Mailing Address - Country:US
Mailing Address - Phone:571-275-1330
Mailing Address - Fax:
Practice Address - Street 1:15533 JOHN DISKIN CIR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-6378
Practice Address - Country:US
Practice Address - Phone:571-275-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist