Provider Demographics
NPI:1174816557
Name:PATIAG, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:PATIAG
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 1:17 PARALLEL ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-2627
Mailing Address - Country:US
Mailing Address - Phone:917-226-9441
Mailing Address - Fax:203-354-2137
Practice Address - Street 1:25 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1960
Practice Address - Country:US
Practice Address - Phone:201-343-2277
Practice Address - Fax:201-343-7410
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01238300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist