Provider Demographics
NPI:1538213418
Name:PALLOTTA, HENRY ALAN (PT)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:ALAN
Last Name:PALLOTTA
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 1:1041 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-3744
Mailing Address - Country:US
Mailing Address - Phone:209-239-4325
Mailing Address - Fax:209-239-2320
Practice Address - Street 1:1041 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3744
Practice Address - Country:US
Practice Address - Phone:209-239-4325
Practice Address - Fax:209-239-2320
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171414000OtherOWCP
CA0PT154280Medicare ID - Type Unspecified