Provider Demographics
NPI:1700403938
Name:PANTELEAKOS, STEPHEN MICHAEL (LAT, ATC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:PANTELEAKOS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10709 VALLEY VIEW RD UNIT A206
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3083
Mailing Address - Country:US
Mailing Address - Phone:206-353-0751
Mailing Address - Fax:
Practice Address - Street 1:12021 NORTHUP WAY STE 102
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1931
Practice Address - Country:US
Practice Address - Phone:425-882-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1613240722255A2300X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer