Provider Demographics
NPI:1396220018
Name:TANTIANGCO, EDWIN (PTA)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:TANTIANGCO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27219 BUCKSKIN TRL
Mailing Address - Street 2:
Mailing Address - City:HARBESON
Mailing Address - State:DE
Mailing Address - Zip Code:19951-2719
Mailing Address - Country:US
Mailing Address - Phone:302-569-0685
Mailing Address - Fax:
Practice Address - Street 1:100 DELAWARE VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-5395
Practice Address - Country:US
Practice Address - Phone:302-424-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0001224225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant