Provider Demographics
NPI:1023251063
Name:RODRIGUEZ, MAURICIO A (PTA)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8582 ELIOT AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1079
Mailing Address - Country:US
Mailing Address - Phone:646-643-5624
Mailing Address - Fax:
Practice Address - Street 1:8582 ELIOT AVE APT 1B
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1079
Practice Address - Country:US
Practice Address - Phone:646-643-5624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005788-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant