Provider Demographics
NPI:1891056529
Name:SIAPNO, ALEX BONGON (PT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:BONGON
Last Name:SIAPNO
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 1:11 FAIRWAY LAKES DR
Mailing Address - Street 2:APT. E21
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-8266
Mailing Address - Country:US
Mailing Address - Phone:305-793-0568
Mailing Address - Fax:
Practice Address - Street 1:3034 S DUPONT BLVD.
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977
Practice Address - Country:US
Practice Address - Phone:302-653-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002773225100000X
TX1215510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist