MEDICARE: YASSER TARIK ELBANNA

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	041412	NY

General Provider Information

NPI Number	:	1619484938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YASSER TARIK ELBANNA

Provider Business Mailing Address
First Line	:	354 91ST ST APT 6D
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-5832
Country	:	US
Telephone Number	:	929-339-6229
Fax Number	:

Provider Business Practice Location Address
First Line	:	1671 W 10TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-1104
Country	:	US
Telephone Number	:	917-499-9955
Fax Number	:

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

Provider Enumeration Date	:	01/08/2018
Last Update Date	:	02/15/2018

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