1104732478 NPI number — JESSE RANDY PANGELINAN DPT, PT

Table of content: JESSE RANDY PANGELINAN DPT, PT (NPI 1104732478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104732478 NPI number — JESSE RANDY PANGELINAN DPT, PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANGELINAN
Provider First Name:
JESSE
Provider Middle Name:
RANDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT, PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104732478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 W SAM HOUSTON PKWY S STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77042-2453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-823-1389
Provider Business Mailing Address Fax Number:
425-820-3996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
947 6TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98033-6712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-823-1389
Provider Business Practice Location Address Fax Number:
425-820-3996
Provider Enumeration Date:
08/19/2026

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT.PT.70143480 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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