Provider Demographics
NPI:1437662400
Name:GUASTAFESTE, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GUASTAFESTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 EDWARDS MILL RD
Mailing Address - Street 2:# 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:718-819-6805
Mailing Address - Fax:
Practice Address - Street 1:180 MICHAEL DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-5328
Practice Address - Country:US
Practice Address - Phone:516-226-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18351225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist