Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | J1-0003957 | DE |
Y | 2251S0007X | Physical Therapist - Sports | 044279 | NY |
NPI | 1376022590 |
---|---|
Provider Name | Thomas Mandala |
First Address | New York, NY 10021 |
Second Address | New York, NY 10021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2018 |
Last Update Date | 13/04/2021 |