MEDICARE: MAYRA ALEJANDRA HERNANDEZ TELLO 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	011019	NY
2	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1255856647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA ALEJANDRA HERNANDEZ TELLO PTA

Provider Business Mailing Address
First Line	:	644 SNEDIKER AV APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207
Country	:	US
Telephone Number	:	917-963-4062
Fax Number	:

Provider Business Practice Location Address
First Line	:	644 SNEDIKER AVE APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-6612
Country	:	US
Telephone Number	:	917-963-4062
Fax Number	:

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

Provider Enumeration Date	:	08/07/2017
Last Update Date	:	08/07/2017

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