Provider Demographics
NPI:1578209474
Name:AVILES, ROSETTE MUTAS
Entity Type:Individual
Prefix:
First Name:ROSETTE
Middle Name:MUTAS
Last Name:AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-3707
Mailing Address - Country:US
Mailing Address - Phone:215-650-1654
Mailing Address - Fax:
Practice Address - Street 1:2850 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1251
Practice Address - Country:US
Practice Address - Phone:716-773-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011726225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant