Provider Demographics
NPI:1033856869
Name:NIEDO, JOSE ANGELO GRACIA (PT)
Entity Type:Individual
Prefix:
First Name:JOSE ANGELO
Middle Name:GRACIA
Last Name:NIEDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 EASTON RD APT 914C
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-2068
Mailing Address - Country:US
Mailing Address - Phone:575-214-1588
Mailing Address - Fax:
Practice Address - Street 1:3300 GRANT AVE STE 20
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2632
Practice Address - Country:US
Practice Address - Phone:877-444-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT030094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist