Provider Demographics
NPI:1710166764
Name:SIASON, ANDREW PANGANORON
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:PANGANORON
Last Name:SIASON
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 1:3290 N RIDGE RD STE 290
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3657
Mailing Address - Country:US
Mailing Address - Phone:443-538-1776
Mailing Address - Fax:
Practice Address - Street 1:3290 N RIDGE RD STE 290
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3657
Practice Address - Country:US
Practice Address - Phone:443-538-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0900003729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist