Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA2154612 | TX |
NPI | 1003572389 |
---|---|
Provider Name | Azure Berry |
First Address | Homosassa, FL 34446-5028 |
Second Address | Arlington, TX 76012-2504 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2021 |
Last Update Date | 11/11/2021 |