Provider Demographics
NPI:1346822418
Name:PANG, GORDON (PT)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:PANG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 VISTA WAY STE 215
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6190
Mailing Address - Country:US
Mailing Address - Phone:442-266-8089
Mailing Address - Fax:442-266-8448
Practice Address - Street 1:2420 VISTA WAY STE 215
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6190
Practice Address - Country:US
Practice Address - Phone:442-266-8089
Practice Address - Fax:442-266-8448
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty