Provider Demographics
NPI:1528477528
Name:BANNAN, PETER (DPT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:BANNAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 ORIENTAL AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2038
Mailing Address - Country:US
Mailing Address - Phone:609-315-2484
Mailing Address - Fax:
Practice Address - Street 1:2305 RANCOCAS RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4113
Practice Address - Country:US
Practice Address - Phone:609-747-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01557100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist