Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 05009156A | IN |
N | 2251G0304X | Physical Therapist - Geriatrics | 1273600 | TX |
NPI | 1063763787 |
---|---|
Provider Name | Daniel Suku Jezreel |
First Address | Cedar Park, TX 78613-4357 |
Second Address | Cedar Park, TX 78613-4357 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2012 |
Last Update Date | 14/12/2020 |