Healthcare Provider Details

I. General information

NPI: 1992157473
Provider Name (Legal Business Name): TREVOR GLENN GLEASON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2291 MARKS RD
CLYMER NY
14724-9742
US

IV. Provider business mailing address

2291 MARKS RD
CLYMER NY
14724-9742
US

V. Phone/Fax

Practice location:
  • Phone: 716-499-9925
  • Fax:
Mailing address:
  • Phone: 716-499-9925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2120638
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: