Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 2251C2600X | Cardiopulmonary |
NPI | 1023689817 |
---|---|
Provider Name | Gavin Mcbride |
First Address | Tigard, OR 97223-1525 |
Second Address | Madison, WI 53705-2254 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2021 |
Last Update Date | 02/07/2021 |