Basic Information
| Provider Information | |||||||||
| NPI: | 1790130383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAGNONI | ||||||||
| FirstName: | ALICIA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 18444 N 25TH AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070022521 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 298427 | 05 | AZ | MEDICAID |