Provider Demographics
NPI:1366722308
Name:PANGEMANAN, IMELDA ALTJI (GNP-BC)
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:ALTJI
Last Name:PANGEMANAN
Suffix:
Gender:F
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4000
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2014-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX721130363LG0600X
TXAP120706363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX859N14OtherBCBS
TX286527101Medicaid
TX286527102Medicaid
TX01609023OtherAMERIGROUP
TXP01025636OtherRAILROAD MEDICARE
TXP01025636OtherRAILROAD MEDICARE
TXTXB140269Medicare PIN