Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 070025302 | IL |
NPI | 1043824584 |
---|---|
Provider Name | Garrett Claxon |
First Address | Pana, IL 62557-4104 |
Second Address | Pana, IL 62557-1421 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2020 |
Last Update Date | 02/09/2020 |