Provider Demographics
NPI:1710566682
Name:MADARIAGA, MYRA FABRIGAS
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:FABRIGAS
Last Name:MADARIAGA
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 1:20 E CHURCH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4618
Mailing Address - Country:US
Mailing Address - Phone:201-562-0535
Mailing Address - Fax:
Practice Address - Street 1:740 VETERANS MEMORIAL HWY STE 210
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2310
Practice Address - Country:US
Practice Address - Phone:201-562-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5929225100000X
NY046706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist