Provider Demographics
NPI:1558874404
Name:PANTOJA, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:PANTOJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13106 SE 240TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-9211
Mailing Address - Country:US
Mailing Address - Phone:253-631-1933
Mailing Address - Fax:253-631-2094
Practice Address - Street 1:13106 SE 240TH ST STE 103
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-9211
Practice Address - Country:US
Practice Address - Phone:253-631-1933
Practice Address - Fax:253-631-2094
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60795204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist