Provider Demographics
NPI:1467935569
Name:PANGAN, ANDREW EDWARD TABASCO (PT)
Entity Type:Individual
Prefix:
First Name:ANDREW EDWARD
Middle Name:TABASCO
Last Name:PANGAN
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 1:1601 FREMONT ST APT 208
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-2660
Mailing Address - Country:US
Mailing Address - Phone:805-710-0793
Mailing Address - Fax:
Practice Address - Street 1:1200 E LANE ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-7210
Practice Address - Country:US
Practice Address - Phone:956-722-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12938602251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1293860OtherPT LICENSE NUMBER