Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2156885 | TX |
NPI | 1003481235 |
---|---|
Provider Name | Cory Raisor |
First Address | Dimmitt, TX 79027-3117 |
Second Address | Macon, MO 63552-2165 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2021 |
Last Update Date | 20/05/2021 |