Provider Demographics
NPI:1659183077
Name:FANG, RANDY (PT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:FANG
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 1:1255 5TH AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3996
Mailing Address - Country:US
Mailing Address - Phone:814-400-1500
Mailing Address - Fax:
Practice Address - Street 1:1 HANSON PL STE 704
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11243-2907
Practice Address - Country:US
Practice Address - Phone:718-857-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist