Healthcare Provider Details

I. General information

NPI: 1174816557
Provider Name (Legal Business Name): RANDY PATIAG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PROSPECT AVE
HACKENSACK NJ
07601-1960
US

IV. Provider business mailing address

17 PARALLEL ST
NORWALK CT
06850-2627
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-2277
  • Fax: 201-343-7410
Mailing address:
  • Phone: 917-226-9441
  • Fax: 203-354-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01238300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: