Healthcare Provider Details

I. General information

NPI: 1215420153
Provider Name (Legal Business Name): MIGUEL TRINIDAD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W 71ST ST
NEW YORK NY
10023-3766
US

IV. Provider business mailing address

860 FAIRMOUNT PL APT 1
BRONX NY
10460-4220
US

V. Phone/Fax

Practice location:
  • Phone: 212-799-0160
  • Fax:
Mailing address:
  • Phone: 347-603-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number011205-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: