Provider Demographics
NPI:1316564172
Name:ORTEGA, ANDRI WARREN G X (PTA)
Entity Type:Individual
Prefix:MR
First Name:ANDRI WARREN
Middle Name:G
Last Name:ORTEGA
Suffix:X
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 1:73 MAPLE AVE APT A2
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3500
Mailing Address - Country:US
Mailing Address - Phone:631-576-6389
Mailing Address - Fax:
Practice Address - Street 1:73 MAPLE AVE APT A2
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3500
Practice Address - Country:US
Practice Address - Phone:631-576-6389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
NY011669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant