Provider Demographics
NPI:1285401802
Name:FORMALE, MICHAEL ANTONIO (PTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTONIO
Last Name:FORMALE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 INWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SCOTCHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13A DICKINSON AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2914
Practice Address - Country:US
Practice Address - Phone:845-353-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013236225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant