Provider Demographics
NPI:1992764864
Name:ETKIN, AUDREY (PT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ETKIN
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 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1954
Practice Address - Street 1:318 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1911
Practice Address - Country:US
Practice Address - Phone:518-478-9049
Practice Address - Fax:518-478-0133
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007713-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA9044Medicare PIN