Provider Demographics
NPI:1376218172
Name:SICANGCO, PAULO HOMERO (PT)
Entity Type:Individual
Prefix:
First Name:PAULO
Middle Name:HOMERO
Last Name:SICANGCO
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 1:2950 MONTILLA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-5526
Mailing Address - Country:US
Mailing Address - Phone:904-805-3455
Mailing Address - Fax:
Practice Address - Street 1:7749 NORMANDY BLVD STE 147
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-7658
Practice Address - Country:US
Practice Address - Phone:904-786-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist