Provider Demographics
NPI:1447785373
Name:PANCHAL, PALAK
Entity Type:Individual
Prefix:
First Name:PALAK
Middle Name:
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 JACKSON PL
Mailing Address - Street 2:
Mailing Address - City:MOONACHIE
Mailing Address - State:NJ
Mailing Address - Zip Code:07074-1212
Mailing Address - Country:US
Mailing Address - Phone:201-709-4149
Mailing Address - Fax:
Practice Address - Street 1:57 JACKSON PL
Practice Address - Street 2:
Practice Address - City:MOONACHIE
Practice Address - State:NJ
Practice Address - Zip Code:07074-1212
Practice Address - Country:US
Practice Address - Phone:201-709-4149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00311700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant