Provider Demographics
NPI:1306485933
Name:LASAM, EMILIO MARQUEZ (PT)
Entity type:Individual
Prefix:
First Name:EMILIO
Middle Name:MARQUEZ
Last Name:LASAM
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 1:3103 34TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2641
Mailing Address - Country:US
Mailing Address - Phone:800-905-0513
Mailing Address - Fax:347-536-3955
Practice Address - Street 1:3310 QUEENS BLVD STE 301
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2302
Practice Address - Country:US
Practice Address - Phone:800-905-0513
Practice Address - Fax:347-536-3955
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045272-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty