Provider Demographics
NPI:1023113776
Name:MICENA, JOHN CHRISTOPHER (MSPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:MICENA
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BOUNDARY AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758
Mailing Address - Country:US
Mailing Address - Phone:516-586-4766
Mailing Address - Fax:516-586-4758
Practice Address - Street 1:200 BOUNDARY AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-586-4766
Practice Address - Fax:516-586-4758
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019608-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ15M41Medicare PIN