Provider Demographics
NPI:1730301029
Name:NOLASCO, MARIO (PT)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:NOLASCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 27TH ST
Mailing Address - Street 2:APT 41
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2332
Mailing Address - Country:US
Mailing Address - Phone:646-288-0962
Mailing Address - Fax:
Practice Address - Street 1:4377 BRONX BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1397
Practice Address - Country:US
Practice Address - Phone:718-325-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQL0131Medicare ID - Type Unspecified