Provider Demographics
NPI:1376570770
Name:PANGBORN, RUSSELL H (PT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:H
Last Name:PANGBORN
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 1:116 MEADOWLAKES DR
Mailing Address - Street 2:
Mailing Address - City:MEADOWLAKES
Mailing Address - State:TX
Mailing Address - Zip Code:78654-6604
Mailing Address - Country:US
Mailing Address - Phone:830-693-0145
Mailing Address - Fax:830-693-0145
Practice Address - Street 1:2312 N HWY 281
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-4360
Practice Address - Country:US
Practice Address - Phone:830-693-9393
Practice Address - Fax:830-693-4097
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist