Provider Demographics
NPI:1396381489
Name:MAISANO, MICHAEL SIMON (ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SIMON
Last Name:MAISANO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MEADOW LEA DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-2830
Mailing Address - Country:US
Mailing Address - Phone:716-907-8242
Mailing Address - Fax:
Practice Address - Street 1:1901 SWEET HOME RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-5312
Practice Address - Country:US
Practice Address - Phone:716-907-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001054-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer