Provider Demographics
NPI:1619629292
Name:PESAYANAVIN, NIPHAN (DPT,PT, LAT,ATC)
Entity Type:Individual
Prefix:
First Name:NIPHAN
Middle Name:
Last Name:PESAYANAVIN
Suffix:
Gender:M
Credentials:DPT,PT, LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:905 OLD WINSTON RD STE B
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-6640
Practice Address - Country:US
Practice Address - Phone:336-992-2787
Practice Address - Fax:336-993-9943
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP6833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist