MEDICARE: DESHAWN DANIEL P.T.A

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	009506	NY

General Provider Information

NPI Number	:	1720538432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESHAWN DANIEL P.T.A

Provider Business Mailing Address
First Line	:	2059 E 55TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2059 EAST 55TH STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4716
Country	:	US
Telephone Number	:	718-744-5175
Fax Number	:

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

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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