Provider Demographics
NPI:1588998348
Name:RADOMSKI, JACEK (PTA)
Entity type:Individual
Prefix:MR
First Name:JACEK
Middle Name:
Last Name:RADOMSKI
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 1:7533 113TH ST
Mailing Address - Street 2:APT 2 F
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7450
Mailing Address - Country:US
Mailing Address - Phone:347-668-3654
Mailing Address - Fax:
Practice Address - Street 1:7533 113TH ST
Practice Address - Street 2:APT 2 F
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7450
Practice Address - Country:US
Practice Address - Phone:347-668-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004880-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant