Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 06004292A | IN |
NPI | 1003225392 |
---|---|
Provider Name | Craig Diss |
First Address | Fort Wayne, IN 46818-8942 |
Second Address | Fort Wayne, IN 46818-8942 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2014 |
Last Update Date | 12/08/2014 |