Provider Demographics
NPI:1043906696
Name:TABUADA, EDWARD GERARD DE PEDRO
Entity type:Individual
Prefix:MR
First Name:EDWARD GERARD
Middle Name:DE PEDRO
Last Name:TABUADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-2923
Mailing Address - Country:US
Mailing Address - Phone:347-586-0625
Mailing Address - Fax:
Practice Address - Street 1:1084 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-2923
Practice Address - Country:US
Practice Address - Phone:347-586-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013214-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant