Provider Demographics
NPI:1508092594
Name:IHESIABA, PETER OGU (PT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:OGU
Last Name:IHESIABA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8818 210TH ST
Mailing Address - Street 2:PH
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2225
Mailing Address - Country:US
Mailing Address - Phone:718-465-0181
Mailing Address - Fax:718-465-0181
Practice Address - Street 1:8818 210TH ST
Practice Address - Street 2:PH
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2225
Practice Address - Country:US
Practice Address - Phone:718-465-0181
Practice Address - Fax:718-465-0181
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013542-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist