Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 1547 | MA |
Y | 222Z00000X | Podiatrist | 1547 | MA |
NPI | 1023112604 |
---|---|
Provider Name | Paul Joseph Pantano II |
First Address | Waltham, MA 02454 |
Second Address | Waltham, MA 02453 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2006 |
Last Update Date | 01/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0340855 | (05) | MA |
T58697 | (02) |