Healthcare Provider Details

I. General information

NPI: 1144253998
Provider Name (Legal Business Name): WAYNE VICTOR HATAMI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST SUITE 103-105
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

475 E MAIN ST SUITE 103-105
PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-0044
  • Fax: 631-447-6126
Mailing address:
  • Phone: 631-289-0044
  • Fax: 631-447-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number016816-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: