Provider Demographics
NPI:1750351474
Name:DABA, NICHOLAS (PTA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DABA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 233
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0233
Mailing Address - Country:US
Mailing Address - Phone:631-725-4450
Mailing Address - Fax:
Practice Address - Street 1:60A BAY ST
Practice Address - Street 2:
Practice Address - City:SAG HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11963-3106
Practice Address - Country:US
Practice Address - Phone:631-725-4450
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0057031225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant