Provider Demographics
NPI:1497475917
Name:DE JESUS, ANDRE WILLIAM JR (PTA)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:WILLIAM
Last Name:DE JESUS
Suffix:JR
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 1:102 LIONEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOLVAY
Mailing Address - State:NY
Mailing Address - Zip Code:13209-2410
Mailing Address - Country:US
Mailing Address - Phone:315-575-7047
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013346-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant