Provider Demographics
NPI:1720858707
Name:PANTALEON, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:PANTALEON
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 1:776 S STATE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5833
Mailing Address - Country:US
Mailing Address - Phone:707-463-4915
Mailing Address - Fax:
Practice Address - Street 1:776 S STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5833
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker