Provider Demographics
NPI:1083869168
Name:FLYNN, JOHN GERARD (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GERARD
Last Name:FLYNN
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 1:8439 153RD AVE
Mailing Address - Street 2:APT 3M
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-1946
Mailing Address - Country:US
Mailing Address - Phone:917-335-5792
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:SUITE 5N
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-8772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006128-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant