Provider Demographics
NPI:1609270669
Name:DERRICO, ANTHONY SR
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DERRICO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-2516
Mailing Address - Country:US
Mailing Address - Phone:518-486-9024
Mailing Address - Fax:
Practice Address - Street 1:20 SUMMIT STREET
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047
Practice Address - Country:US
Practice Address - Phone:518-486-9024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003212-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant