Provider Demographics
NPI:1063725018
Name:NAGARKAR, KETAKI
Entity type:Individual
Prefix:
First Name:KETAKI
Middle Name:
Last Name:NAGARKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KETAKI
Other - Middle Name:
Other - Last Name:PETHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 CENTURY HILL DR STE 104
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2151
Mailing Address - Country:US
Mailing Address - Phone:518-713-4106
Mailing Address - Fax:
Practice Address - Street 1:11 CENTURY HILL DR STE 104
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-713-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist