Provider Demographics
NPI:1255029955
Name:BANIWAS, JOSHUA KYLE TINDAAN
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:KYLE TINDAAN
Last Name:BANIWAS
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 1:3832 PERIDOT CT
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-7287
Mailing Address - Country:US
Mailing Address - Phone:180-527-6806
Mailing Address - Fax:
Practice Address - Street 1:1440 S EUCLID ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2156
Practice Address - Country:US
Practice Address - Phone:714-535-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51374225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant