Provider Demographics
NPI:1417422841
Name:GARCIA, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GARCIA
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 1:55 NORTHERN BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4058
Mailing Address - Country:US
Mailing Address - Phone:516-466-9300
Mailing Address - Fax:
Practice Address - Street 1:55 NORTHERN BLVD STE 103
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4058
Practice Address - Country:US
Practice Address - Phone:516-466-9300
Practice Address - Fax:516-466-9353
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012900-01225200000X
NYP14271225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225200000Medicaid