Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 2251X0800X | Physical Therapist - Orthopedic | 63405 | OR |
NPI | 1003461823 |
---|---|
Provider Name | Charlo Brandon Crumpacker |
First Address | Hoover, AL 35242-2941 |
Second Address | Oregon City, OR 97045-4004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2019 |
Last Update Date | 09/03/2021 |