Provider Demographics
NPI:1174003230
Name:DISTEFANO, ANTHONY MICHAEL (PTA)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:DISTEFANO
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 1:910 FOULK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3158
Mailing Address - Country:US
Mailing Address - Phone:302-477-1536
Mailing Address - Fax:302-477-1564
Practice Address - Street 1:910 FOULK RD STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3158
Practice Address - Country:US
Practice Address - Phone:302-477-1536
Practice Address - Fax:302-477-1564
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0001272225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant