Provider Demographics
NPI:1568007623
Name:BAN, MYEONGJI (DPT)
Entity Type:Individual
Prefix:
First Name:MYEONGJI
Middle Name:
Last Name:BAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14021 32ND AVE APT 7EN
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-2663
Mailing Address - Country:US
Mailing Address - Phone:224-423-8053
Mailing Address - Fax:
Practice Address - Street 1:13525 79TH ST STE 2A
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-1010
Practice Address - Country:US
Practice Address - Phone:224-423-8053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38931225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist