Healthcare Provider Details

I. General information

NPI: 1326363177
Provider Name (Legal Business Name): ANTONIO ABAN LAXA III PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 MALDON ST
MALVERNE NY
11565-1515
US

IV. Provider business mailing address

36 MALDON ST
MALVERNE NY
11565-1515
US

V. Phone/Fax

Practice location:
  • Phone: 917-974-6485
  • Fax: 516-837-9486
Mailing address:
  • Phone: 917-974-6485
  • Fax: 516-837-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberP.T. 018945-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: