Provider Demographics
NPI:1275011066
Name:VANKOUWENBERG, CONNOR (PT DPT)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:VANKOUWENBERG
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 8000 DEPT 314
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:716-213-0772
Mailing Address - Fax:716-324-5004
Practice Address - Street 1:48 DOUGLAS LN
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2124
Practice Address - Country:US
Practice Address - Phone:716-714-9860
Practice Address - Fax:716-714-9864
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043542225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist