Provider Demographics
NPI:1700925880
Name:CONANAN, AMADO E (PT)
Entity Type:Individual
Prefix:
First Name:AMADO
Middle Name:E
Last Name:CONANAN
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 1:5718 WOODSIDE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3444
Mailing Address - Country:US
Mailing Address - Phone:718-205-0030
Mailing Address - Fax:718-205-6136
Practice Address - Street 1:5718 WOODSIDE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3444
Practice Address - Country:US
Practice Address - Phone:718-205-0030
Practice Address - Fax:718-205-6136
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY022161225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02527282Medicaid
NYA100033215Medicare UPIN
NY07507Medicare UPIN