Provider Demographics
NPI:1659148542
Name:RESANO, JIVAN RAY LEONIDA (PTA)
Entity Type:Individual
Prefix:MR
First Name:JIVAN RAY
Middle Name:LEONIDA
Last Name:RESANO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:J IVAN RAY
Other - Middle Name:LEONIDA
Other - Last Name:RESANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:9128 PARK LN S
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1432
Mailing Address - Country:US
Mailing Address - Phone:808-342-4208
Mailing Address - Fax:
Practice Address - Street 1:9128 PARK LN S
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1432
Practice Address - Country:US
Practice Address - Phone:808-342-4208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014020225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant