Provider Demographics
NPI:1861699092
Name:PANBAMRUNG, ANTHONY KHUNTONG (PTA)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:KHUNTONG
Last Name:PANBAMRUNG
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 1:3516 UTAH DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6640
Mailing Address - Country:US
Mailing Address - Phone:260-385-3517
Mailing Address - Fax:260-492-1674
Practice Address - Street 1:2827 NORTHGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2903
Practice Address - Country:US
Practice Address - Phone:260-492-1498
Practice Address - Fax:260-492-1674
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002861A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1555-656Medicaid