Provider Demographics
NPI:1497976161
Name:YAGNETINSKY, GENNADY (MSPT)
Entity Type:Individual
Prefix:MR
First Name:GENNADY
Middle Name:
Last Name:YAGNETINSKY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BOSWELL RD
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-2810
Mailing Address - Country:US
Mailing Address - Phone:845-603-6339
Mailing Address - Fax:845-603-6339
Practice Address - Street 1:61 BOSWELL RD
Practice Address - Street 2:
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-2810
Practice Address - Country:US
Practice Address - Phone:845-603-6339
Practice Address - Fax:845-603-6339
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023608-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02242780Medicaid
NYQN0671Medicare ID - Type Unspecified