Provider Demographics
NPI:1932401825
Name:GANDEZA, ROLAND ANCHETA (PT)
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:ANCHETA
Last Name:GANDEZA
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 1:333 E 102ND ST APT 721
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5664
Mailing Address - Country:US
Mailing Address - Phone:917-775-4579
Mailing Address - Fax:
Practice Address - Street 1:333 E 102ND ST APT 721
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5664
Practice Address - Country:US
Practice Address - Phone:917-775-4579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-26
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist