MEDICARE: JOSE ANGELO GRACIA NIEDO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT030094	PA

General Provider Information

NPI Number	:	1033856869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE ANGELO GRACIA NIEDO PT

Provider Business Mailing Address
First Line	:	1003 EASTON RD APT 914C
Second Line	:
City	:	WILLOW GROVE
State	:	PA
Zip	:	19090-2068
Country	:	US
Telephone Number	:	575-214-1588
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 GRANT AVE STE 20
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-2632
Country	:	US
Telephone Number	:	877-444-2422
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2022
Last Update Date	:	05/13/2022

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