Healthcare Provider Details

I. General information

NPI: 1427528637
Provider Name (Legal Business Name): JACOB DAVID URBAN PTA, CSCS, FMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2745 COLONIAL AVE
MERRICK NY
11566-4906
US

IV. Provider business mailing address

2745 COLONIAL AVE
MERRICK NY
11566-4906
US

V. Phone/Fax

Practice location:
  • Phone: 718-801-4618
  • Fax:
Mailing address:
  • Phone: 718-801-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number011200
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: