Basic Information
| Provider Information | |||||||||
| NPI: | 1174003230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISTEFANO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 FOULK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024771536 | ||||||||
| FaxNumber: | 3024771564 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 FOULK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024771536 | ||||||||
| FaxNumber: | 3024771564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2018 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | J2-0001272 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.