=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306563952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYCIA MARIE YAX PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2022
-----------------------------------------------------
Last Update Date | 10/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 GRAND ISLAND BLVD
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14072-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-773-4323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10789 TINKHAM RD
-----------------------------------------------------
City | DARIEN CENTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14040-9757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 013466-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------