Provider Demographics
NPI:1639525488
Name:WANGDU, TENZIN (PT)
Entity Type:Individual
Prefix:
First Name:TENZIN
Middle Name:
Last Name:WANGDU
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 1:1096 WEST ST # 426
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1037
Mailing Address - Country:US
Mailing Address - Phone:209-704-5795
Mailing Address - Fax:
Practice Address - Street 1:948 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-2010
Practice Address - Country:US
Practice Address - Phone:510-526-2353
Practice Address - Fax:510-526-2022
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist