Healthcare Provider Details

I. General information

NPI: 1326544693
Provider Name (Legal Business Name): ANTHONY FUENTES DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EISENHOWER DR
EAST QUOGUE NY
11942-4730
US

IV. Provider business mailing address

107 AUBORN AVE
SHIRLEY NY
11967-1739
US

V. Phone/Fax

Practice location:
  • Phone: 617-319-6367
  • Fax:
Mailing address:
  • Phone: 631-741-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP09803
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: