Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 06001403A | IN |
NPI | 1023148327 |
---|---|
Provider Name | Brian Lee Stoll |
First Address | Jasper, IN 47546-9145 |
Second Address | Jasper, IN 47546-9145 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
06001403A | INDIANA STATE LICENSE (01) | IN |