Provider Demographics
NPI:1962153908
Name:PANGANIBAN, RYAN JOSEPH (PTA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOSEPH
Last Name:PANGANIBAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-1435
Mailing Address - Country:US
Mailing Address - Phone:630-788-5184
Mailing Address - Fax:
Practice Address - Street 1:26W171 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-6002
Practice Address - Country:US
Practice Address - Phone:630-909-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009263225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant