Provider Demographics
NPI:1396353413
Name:AGUINALDO, IAN PANELO (DPT, MSPT)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:PANELO
Last Name:AGUINALDO
Suffix:
Gender:M
Credentials:DPT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WILDROSE LN APT B
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1216
Mailing Address - Country:US
Mailing Address - Phone:618-751-2466
Mailing Address - Fax:
Practice Address - Street 1:6 E SHAWNEE DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-7048
Practice Address - Country:US
Practice Address - Phone:618-684-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294711225100000X
FLPT34228225100000X
IL070.021846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist