Provider Demographics
NPI:1891939625
Name:YOO, SAMUEL SANGWON (PT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SANGWON
Last Name:YOO
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 1:3930 RICHMOND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5103
Mailing Address - Country:US
Mailing Address - Phone:646-240-8453
Mailing Address - Fax:
Practice Address - Street 1:3930 RICHMOND AVE STE 200
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5103
Practice Address - Country:US
Practice Address - Phone:646-240-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400061606OtherMEDICARE MEMBER PTAN FOR QUEENS
NYA400026932OtherMEDICARE MEMBER PTAN FOR BROOKLYN, STATEN ISLAND, MANHATTAN
NY1891939625Medicaid