Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT25505 | CA |
NPI | 1003056797 |
---|---|
Provider Name | Christopher P Derosa |
First Address | El Segundo, CA 90245-3814 |
Second Address | El Segundo, CA 90245-3814 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2009 |
Last Update Date | 31/12/2013 |