Provider Demographics
NPI:1639944523
Name:INNOCENZI, PAUL (PTA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:INNOCENZI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820 SUMMERSET DR
Mailing Address - Street 2:
Mailing Address - City:WALTON HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-4964
Mailing Address - Country:US
Mailing Address - Phone:440-821-1270
Mailing Address - Fax:
Practice Address - Street 1:646 16TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3709
Practice Address - Country:US
Practice Address - Phone:503-325-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant