Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | AT 6118 | CA |
NPI | 1003137043 |
---|---|
Provider Name | Amy Fose |
First Address | Moreno Valley, CA 92553-6848 |
Second Address | San Diego, CA 92111-2276 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2010 |
Last Update Date | 14/06/2010 |