Provider Demographics
NPI:1629084736
Name:PINCKNEY, MICHAEL TYRAE (DPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TYRAE
Last Name:PINCKNEY
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 1:15 NEIL CT
Mailing Address - Street 2:INSIDE FRIEDBERG JCC
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5815
Mailing Address - Country:US
Mailing Address - Phone:516-766-0505
Mailing Address - Fax:516-766-0680
Practice Address - Street 1:15 NEIL CT
Practice Address - Street 2:INSIDE FRIEDBERG JCC
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5815
Practice Address - Country:US
Practice Address - Phone:516-766-0505
Practice Address - Fax:516-766-0680
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027136-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ35D31Medicare UPIN
NY07237Medicare ID - Type Unspecified