Provider Demographics
NPI:1205597770
Name:SAMANIEGO, MOISES ALEXANDER
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:ALEXANDER
Last Name:SAMANIEGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SELKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12158-1230
Mailing Address - Country:US
Mailing Address - Phone:518-894-3592
Mailing Address - Fax:
Practice Address - Street 1:28 WILDWOOD LN
Practice Address - Street 2:
Practice Address - City:SELKIRK
Practice Address - State:NY
Practice Address - Zip Code:12158-1230
Practice Address - Country:US
Practice Address - Phone:518-894-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113720-01224Z00000X
NY011282224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant