Provider Demographics
NPI:1891359311
Name:PANGBORN, SAMANTHA MARIE (PT, DPT, MS)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:PANGBORN
Suffix:
Gender:F
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 S 83RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1030
Mailing Address - Country:US
Mailing Address - Phone:414-588-7187
Mailing Address - Fax:
Practice Address - Street 1:4805 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7401
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14658-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist