Provider Demographics
NPI:1497092662
Name:SAN JOSE, ANGELA LOPEZ (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LOPEZ
Last Name:SAN JOSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 78TH ST APT 514
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1919
Mailing Address - Country:US
Mailing Address - Phone:347-605-8261
Mailing Address - Fax:
Practice Address - Street 1:1765 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1611
Practice Address - Country:US
Practice Address - Phone:347-605-8261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist