Provider Demographics
NPI:1780270215
Name:LAGO, MATTHEW (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LAGO
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3072 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6214
Mailing Address - Country:US
Mailing Address - Phone:631-462-9595
Mailing Address - Fax:
Practice Address - Street 1:3072 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6214
Practice Address - Country:US
Practice Address - Phone:631-462-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046491-012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic