MEDICARE: DR. IJUNANYA HOLDER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	028416	NY

General Provider Information

NPI Number	:	1225255789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IJUNANYA HOLDER DPT

Provider Business Mailing Address
First Line	:	2 SHERMAN POTTS DR
Second Line	:	SUITE 202
City	:	GHENT
State	:	NY
Zip	:	12075-3216
Country	:	US
Telephone Number	:	518-965-6099
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 SHERMAN POTTS DR
Second Line	:	SUITE 202
City	:	GHENT
State	:	NY
Zip	:	12075-3216
Country	:	US
Telephone Number	:	518-965-6099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	11/11/2014

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