Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA.0014491 | CO |
NPI | 1003438094 |
---|---|
Provider Name | Bret Cory Bishop |
First Address | Fountain, CO 80817-1693 |
Second Address | Pueblo, CO 81008-2218 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2020 |
Last Update Date | 12/05/2020 |