Provider Demographics
NPI:1144253998
Name:HATAMI, WAYNE VICTOR (PT)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:VICTOR
Last Name:HATAMI
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 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-289-0044
Mailing Address - Fax:631-447-6126
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 103-105
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-289-0044
Practice Address - Fax:631-447-6126
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016816-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ45872Medicare ID - Type UnspecifiedPHYSICAL THERAPIST
NY03838GMedicare PIN