Provider Demographics
NPI:1164964094
Name:BANDASAK, NATTY
Entity Type:Individual
Prefix:
First Name:NATTY
Middle Name:
Last Name:BANDASAK
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 1:75 STERLING BLVD
Mailing Address - Street 2:APT 550
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4846
Mailing Address - Country:US
Mailing Address - Phone:201-561-4681
Mailing Address - Fax:949-561-4171
Practice Address - Street 1:55 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-3143
Practice Address - Country:US
Practice Address - Phone:201-561-4681
Practice Address - Fax:949-561-4171
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01701300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist