MEDICARE: EDMUND GONSALVES-SABOLA

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	225200000X	Physical Therapy Assistant	007288	NY

General Provider Information

NPI Number	:	1710470356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDMUND GONSALVES-SABOLA

Provider Business Mailing Address
First Line	:	2011 OCEAN AVE APT 3E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6812
Country	:	US
Telephone Number	:	718-377-5000
Fax Number	:	718-377-5002

Provider Business Practice Location Address
First Line	:	2011 OCEAN AVE APT 3E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6812
Country	:	US
Telephone Number	:	718-377-5000
Fax Number	:	718-377-5002

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

Provider Enumeration Date	:	06/08/2018
Last Update Date	:	06/08/2018

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