Provider Demographics
NPI:1104532977
Name:GERONIMO, CHARMAINE TARCA
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:TARCA
Last Name:GERONIMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4617
Mailing Address - Country:US
Mailing Address - Phone:718-252-0625
Mailing Address - Fax:
Practice Address - Street 1:2918 AVENUE M
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4617
Practice Address - Country:US
Practice Address - Phone:718-252-0625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041826-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N0119036225OtherDRIVER'S LICENSE