=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326363177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONIO ABAN LAXA III PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2010
-----------------------------------------------------
Last Update Date | 04/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 MALDON ST
-----------------------------------------------------
City | MALVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11565-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-974-6485
-----------------------------------------------------
Fax | 516-837-9486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 MALDON ST
-----------------------------------------------------
City | MALVERNE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11565-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-974-6485
-----------------------------------------------------
Fax | 516-837-9486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | P.T. 018945-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------