Provider Demographics
NPI:1437169323
Name:MAGGARD, MICHAEL JASON (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JASON
Last Name:MAGGARD
Suffix:
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 1:198 AVENUE A APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-3401
Mailing Address - Country:US
Mailing Address - Phone:917-674-3950
Mailing Address - Fax:
Practice Address - Street 1:897 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1205
Practice Address - Country:US
Practice Address - Phone:212-674-7878
Practice Address - Fax:212-673-7878
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006306-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006306-1OtherLICENSE NUMBER