Provider Demographics
NPI:1073726899
Name:DE MONTAGNAC, ANDRE PATRICK (PT)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:PATRICK
Last Name:DE MONTAGNAC
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 1:4210 COLDEN ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4845
Mailing Address - Country:US
Mailing Address - Phone:718-321-8910
Mailing Address - Fax:718-321-9022
Practice Address - Street 1:4210 COLDEN ST
Practice Address - Street 2:SUITE 209
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4845
Practice Address - Country:US
Practice Address - Phone:718-321-8910
Practice Address - Fax:718-321-9022
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02285418Medicaid
NY02285418Medicaid