Provider Demographics
NPI:1861649006
Name:IZURIETA, ANTHONY PETER (PTA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:PETER
Last Name:IZURIETA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GRACE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4719
Mailing Address - Country:US
Mailing Address - Phone:973-634-0633
Mailing Address - Fax:
Practice Address - Street 1:2300 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3007
Practice Address - Country:US
Practice Address - Phone:609-588-5823
Practice Address - Fax:609-588-5580
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00220700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant