Provider Demographics
NPI:1073698148
Name:PROSSER, CHARLES DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DAVID
Last Name:PROSSER
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 1:304 FIRST ST
Mailing Address - Street 2:MULTISPORT PHYSICAL THERAPY AND FITNESS PLLC
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-451-2270
Mailing Address - Fax:315-451-2271
Practice Address - Street 1:304 FIRST ST
Practice Address - Street 2:MULTISPORT PHYSICAL THERAPY AND FITNESS PLLC
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-451-2270
Practice Address - Fax:315-451-2271
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA5616OtherPIN