Provider Demographics
NPI:1437909074
Name:NUNAG, CHARLES GENREV C (COTA)
Entity Type:Individual
Prefix:
First Name:CHARLES GENREV
Middle Name:C
Last Name:NUNAG
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8848 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7934
Mailing Address - Country:US
Mailing Address - Phone:929-231-7460
Mailing Address - Fax:
Practice Address - Street 1:8848 RUTLEDGE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7934
Practice Address - Country:US
Practice Address - Phone:929-231-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010380-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant