Provider Demographics
NPI:1245975663
Name:INCIONG, GLENN PATRICK KATIGBAC
Entity type:Individual
Prefix:
First Name:GLENN PATRICK
Middle Name:KATIGBAC
Last Name:INCIONG
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 1:5124 VAN LOON ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4255
Mailing Address - Country:US
Mailing Address - Phone:929-289-3995
Mailing Address - Fax:
Practice Address - Street 1:1345 AVENUE OF THE AMERICAS
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10105-0302
Practice Address - Country:US
Practice Address - Phone:212-981-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011961-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant