Healthcare Provider Details

I. General information

NPI: 1821918079
Provider Name (Legal Business Name): MYKIEL JERICHO AGUSTIN ESCOBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9046 54TH AVE #3
ELMHURST NY
11373
US

IV. Provider business mailing address

9046 54TH AVE #3
ELMHURST NY
11373
US

V. Phone/Fax

Practice location:
  • Phone: 347-829-3890
  • Fax: 347-829-3888
Mailing address:
  • Phone: 347-829-3890
  • Fax: 347-829-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number014218
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: