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Provider Information for 1225464753

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1225464753

Calendar   Last Updated:  2014-07-28
  Certification Date: 


Name Value
NPI 1225464753
Enumeration Date 2013-09-16
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 6319 FLY RD SUITE 3
EAST SYRACUSE, NY 13057-9357
United States

Phone: 315-410-6200 | Fax: 315-451-2095
View Map External Link
Primary Practice Address 314 E 1ST ST
EAST SYRACUSE, NY 13057-2927
United States

Phone: 315-439-8840 | Fax: 315-410-5554
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 225100000X - Physical Therapist NY 036840