Provider Demographics
NPI:1326363177
Name:LAXA, ANTONIO ABAN III (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:ABAN
Last Name:LAXA
Suffix:III
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MALDON ST
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1515
Mailing Address - Country:US
Mailing Address - Phone:917-974-6485
Mailing Address - Fax:516-837-9486
Practice Address - Street 1:36 MALDON ST
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1515
Practice Address - Country:US
Practice Address - Phone:917-974-6485
Practice Address - Fax:516-837-9486
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP.T. 018945-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker