Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | OP002984L | PA |
NPI | 1013487628 |
---|---|
Provider Name | Chris Farnsworth |
First Address | Drexel Hill, PA 19026-4201 |
Second Address | Drexel Hill, PA 19026-4201 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/11/2018 |
Last Update Date | 27/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
QCH121028785001 | KEYSTONE (01) | PA |