Provider Demographics
NPI:1548416035
Name:MIKRUT, EVA AGNES (DPT)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:AGNES
Last Name:MIKRUT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6024 60TH DR
Mailing Address - Street 2:APT #3C
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-3500
Mailing Address - Country:US
Mailing Address - Phone:917-482-4597
Mailing Address - Fax:
Practice Address - Street 1:6024 60TH DR
Practice Address - Street 2:APT #3C
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-3500
Practice Address - Country:US
Practice Address - Phone:917-482-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003555-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist