Healthcare Provider Details

I. General information

NPI: 1053250035
Provider Name (Legal Business Name): IVAN OQUINENA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WATERS PL STE 903
BRONX NY
10461-2733
US

IV. Provider business mailing address

1602 EDISON AVE APT 1
BRONX NY
10461-4800
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-9313
  • Fax: 718-430-9314
Mailing address:
  • Phone: 646-299-3674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number015196
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: