Provider Demographics
NPI:1083328751
Name:TUPAZ, JAN KEVYN MAXINO (PT)
Entity type:Individual
Prefix:
First Name:JAN KEVYN
Middle Name:MAXINO
Last Name:TUPAZ
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 1:349 VALLEY ST FL 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2857
Mailing Address - Country:US
Mailing Address - Phone:917-349-6347
Mailing Address - Fax:
Practice Address - Street 1:799 MORRIS PARK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-3604
Practice Address - Country:US
Practice Address - Phone:718-684-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014731-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant