Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 024825 | NY |
NPI | 1114121076 |
---|---|
Provider Name | Mr. Oliver Jay Realino |
First Address | New York, NY 10010-6119 |
Second Address | New York, NY 10011-6307 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2007 |
Last Update Date | 08/07/2007 |