Basic Information
| Provider Information | |||||||||
| NPI: | 1770216590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUEZADA | ||||||||
| FirstName: | AUGUSTO | ||||||||
| MiddleName: | RENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 64 NEW YORK AVE NE FL 3 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200023328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026732200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 ALABAMA AVE SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200324542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2022995100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2022 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251G0304X | PT2608 | DC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 225100000X | PT2608 | DC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1538254016 | 05 | DC | MEDICAID | 1871634170 | 05 | DC | MEDICAID |