Provider Demographics
NPI:1649740341
Name:DEGAETANO, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:DEGAETANO
Suffix:
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 1:1521 HILLCREST LN
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-3518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1521 HILLCREST LN
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-3518
Practice Address - Country:US
Practice Address - Phone:484-883-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program