Provider Demographics
NPI:1871534339
Name:PANOS, ROSA (PT, AP, DIPL OM)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:PANOS
Suffix:
Gender:F
Credentials:PT, AP, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-3723
Mailing Address - Country:US
Mailing Address - Phone:386-447-0610
Mailing Address - Fax:386-447-0670
Practice Address - Street 1:397 PALM COAST PKWY SW UNIT 5
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4777
Practice Address - Country:US
Practice Address - Phone:386-447-0610
Practice Address - Fax:386-447-0670
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
FLPT 22203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9607Medicare ID - Type UnspecifiedGROUP #
FLY091SZMedicare ID - Type UnspecifiedPROVIDER NUMBER