Provider Demographics
NPI:1396309910
Name:MANOSAN, PRUETTIYAPA (PT)
Entity type:Individual
Prefix:MISS
First Name:PRUETTIYAPA
Middle Name:
Last Name:MANOSAN
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 1:2707 CRESTON AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3624
Mailing Address - Country:US
Mailing Address - Phone:347-536-6653
Mailing Address - Fax:
Practice Address - Street 1:531 W 235TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1795
Practice Address - Country:US
Practice Address - Phone:718-432-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011090225200000X
NY044217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant