Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 12383 | AZ |
N | 2251S0007X | Physical Therapist - Sports | ||
N | 2251X0800X | Physical Therapist - Orthopedic |
NPI | 1063966554 |
---|---|
Provider Name | Ethan Anderson |
First Address | Phoenix, AZ 85044-6691 |
Second Address | Peoria, AZ 85382-2101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2016 |
Last Update Date | 12/08/2016 |