Healthcare Provider Details

I. General information

NPI: 1790612935
Provider Name (Legal Business Name): EARVIN YGNACIO LUCIO JEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W END AVE APT 1M
NEW YORK NY
10023-5715
US

IV. Provider business mailing address

231 W 149TH ST
NEW YORK NY
10039-2704
US

V. Phone/Fax

Practice location:
  • Phone: 121-260-0478
  • Fax:
Mailing address:
  • Phone: 646-818-5479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number015379-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: