Provider Demographics
NPI:1285760710
Name:NISPEROS, M. P. (PT)
Entity type:Individual
Prefix:
First Name:M. P.
Middle Name:
Last Name:NISPEROS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:MANGAOANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:53 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1805
Mailing Address - Country:US
Mailing Address - Phone:973-704-7734
Mailing Address - Fax:855-631-4348
Practice Address - Street 1:517 CENTRAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-1433
Practice Address - Country:US
Practice Address - Phone:973-414-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01110500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ117788TVNMedicare PIN