Provider Demographics
NPI:1770249914
Name:NA, YOUNGSU (PT)
Entity type:Individual
Prefix:
First Name:YOUNGSU
Middle Name:
Last Name:NA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BROADWAY STE 1219
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-3834
Mailing Address - Country:US
Mailing Address - Phone:929-412-2654
Mailing Address - Fax:929-412-2686
Practice Address - Street 1:42 BROADWAY STE 1219
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-3834
Practice Address - Country:US
Practice Address - Phone:929-412-2654
Practice Address - Fax:929-412-2686
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY043571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist