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Individual

BERGEN BUTALA

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
750 E ADAMS ST, SYRACUSE, NY 13210-2306
(612) 801-1520
Mailing address
210 W DIVISION ST APT 40, SYRACUSE, NY 13204-1592

Taxonomy

Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
039190-1
NY

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
00354590
NY
Enumeration date
08/18/2015
Last updated
08/18/2015
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