Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 028810 | NY |
NPI | 1003018920 |
---|---|
Provider Name | Mr. Nino Pompeyo Rocco Altamirano Borja |
First Address | West Hempstead, NY 11552-2528 |
Second Address | East Patchogue, NY 11772-8810 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2007 |
Last Update Date | 20/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
06050059 | (05) | NY |
12029482 | CAQH (01) |