Provider Demographics
NPI:1689033953
Name:PANUSHKA, MARY HELEN (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HELEN
Last Name:PANUSHKA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25100 VISTA MURRIETA APT 3436
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-2935
Mailing Address - Country:US
Mailing Address - Phone:805-205-3110
Mailing Address - Fax:
Practice Address - Street 1:3989 W STETSON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9695
Practice Address - Country:US
Practice Address - Phone:951-652-3334
Practice Address - Fax:951-652-3335
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA195325Medicare PIN
CACA195324Medicare PIN
CACA195326Medicare PIN
CACB257259Medicare PIN