Provider Demographics
NPI:1053362632
Name:MARRA, ANTHONY JOHN (ATC)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JOHN
Last Name:MARRA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-1930
Mailing Address - Country:US
Mailing Address - Phone:516-628-8269
Mailing Address - Fax:
Practice Address - Street 1:601 FRANKLIN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5795
Practice Address - Country:US
Practice Address - Phone:516-248-1314
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000530-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer