Provider Demographics
NPI:1194180190
Name:MCNELIS, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MCNELIS
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 1:221 BEACH 117TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2056
Mailing Address - Country:US
Mailing Address - Phone:347-287-5812
Mailing Address - Fax:
Practice Address - Street 1:221 BEACH 117TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2056
Practice Address - Country:US
Practice Address - Phone:347-287-5812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039100-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist