Provider Demographics
NPI:1154880623
Name:SUMAMPONG, TRISILYN VIRADOR (PT)
Entity type:Individual
Prefix:MRS
First Name:TRISILYN
Middle Name:VIRADOR
Last Name:SUMAMPONG
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 1:4160 74TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1847
Mailing Address - Country:US
Mailing Address - Phone:516-830-1787
Mailing Address - Fax:
Practice Address - Street 1:21714 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1917
Practice Address - Country:US
Practice Address - Phone:347-270-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist