MEDICARE: EKOUEGAN EKOUE-TOTOU PTA

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	225200000X	Physical Therapy Assistant	005567-1	NY

General Provider Information

NPI Number	:	1245428150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EKOUEGAN EKOUE-TOTOU PTA

Provider Business Mailing Address
First Line	:	22 PERRIN ST
Second Line	:
City	:	ROXBURY
State	:	MA
Zip	:	02119-2107
Country	:	US
Telephone Number	:	617-290-9627
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 STONE ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3211
Country	:	US
Telephone Number	:	315-782-7400
Fax Number	:

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

Provider Enumeration Date	:	10/05/2007
Last Update Date	:	10/05/2007

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