Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 26768 | CA |
N | 2251H1200X | Hand | ||
Y | 2251H1200X | Hand | 26768 | CA |
NPI | 1164627436 |
---|---|
Provider Name | Audra Ponci Bado |
First Address | Culver Cite, CA 90066 |
Second Address | Los Angeles, CA 90066-2621 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2007 |
Last Update Date | 23/05/2017 |