Basic Information
Provider Information | |||||||||
NPI: | 1811959950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKAY | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.T.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 37 COBBLESTONE DR | ||||||||
Address2: |   | ||||||||
City: | SHOREHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 117862311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6318493447 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 MIDDLE COUNTRY RD | ||||||||
Address2: | SUITE G - LONGWOOD SPORTS THERAPY | ||||||||
City: | CORAM | ||||||||
State: | NY | ||||||||
PostalCode: | 117274410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317162700 | ||||||||
FaxNumber: | 6317162782 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 001153 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.