Provider Demographics
NPI:1588987267
Name:EVIDENTE, PETER RAYMUND MAGBANUA (PT)
Entity type:Individual
Prefix:
First Name:PETER RAYMUND
Middle Name:MAGBANUA
Last Name:EVIDENTE
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 1:1628 JOHN F KENNEDY BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-2120
Mailing Address - Country:US
Mailing Address - Phone:215-557-0057
Mailing Address - Fax:
Practice Address - Street 1:1628 JOHN F KENNEDY BLVD STE 401
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-2120
Practice Address - Country:US
Practice Address - Phone:215-557-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist