Provider Demographics
NPI:1578504387
Name:PANOS, HEIDI LEIGH (MPT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEIGH
Last Name:PANOS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LEIGH
Other - Last Name:SITES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:808-674-9696
Practice Address - Street 1:1000 SOUTH COLUMBIA ROAD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58206-6002
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:808-674-9696
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1338225100000X
HI2281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000242578OtherHMSA 65C/C
HI53799601Medicaid
HI53799601Medicaid