Provider Demographics
NPI:1942525217
Name:CAYETUNA, NATHANIEL BREX ROA (PT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL BREX
Middle Name:ROA
Last Name:CAYETUNA
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 1:4312 JUDGE ST APT 1R
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-3476
Mailing Address - Country:US
Mailing Address - Phone:646-714-1392
Mailing Address - Fax:
Practice Address - Street 1:4312 JUDGE ST APT 1R
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-3476
Practice Address - Country:US
Practice Address - Phone:646-714-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist