Provider Demographics
NPI:1679297444
Name:DE TOMAS, JESEL MAY LACANA
Entity Type:Individual
Prefix:
First Name:JESEL MAY
Middle Name:LACANA
Last Name:DE TOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 MAIN ST APT 740
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-0171
Mailing Address - Country:US
Mailing Address - Phone:409-354-0744
Mailing Address - Fax:
Practice Address - Street 1:8916 175TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5549
Practice Address - Country:US
Practice Address - Phone:718-487-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist