MEDICARE: ALIS GAMZEHLATOVA PTA

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	005557	NY

General Provider Information

NPI Number	:	1932792470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALIS GAMZEHLATOVA PTA

Provider Business Mailing Address
First Line	:	1240 E 19TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5404
Country	:	US
Telephone Number	:	718-377-5000
Fax Number	:	718-377-5002

Provider Business Practice Location Address
First Line	:	1240 E 19TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-5404
Country	:	US
Telephone Number	:	718-377-5000
Fax Number	:	718-377-5002

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

Provider Enumeration Date	:	02/16/2021
Last Update Date	:	02/16/2021

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Directions to “ ALIS GAMZEHLATOVA PTA” Practice Location

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