Healthcare Provider Details

I. General information

NPI: 1477271609
Provider Name (Legal Business Name): CONNOR MATTHEW VLASATY PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E GATE BLVD
GARDEN CITY NY
11530-2105
US

IV. Provider business mailing address

2 ADDISON LN
GREENVALE NY
11548-1120
US

V. Phone/Fax

Practice location:
  • Phone: 516-745-8050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number049172
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: