Healthcare Provider Details

I. General information

NPI: 1902762982
Provider Name (Legal Business Name): JERRICKO ANDRE TAASAN RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10425 88TH AVE
RICHMOND HILL NY
11418-2132
US

IV. Provider business mailing address

10425 88TH AVE
RICHMOND HILL NY
11418-2132
US

V. Phone/Fax

Practice location:
  • Phone: 279-977-8306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number055398
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number014377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: