Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 1012 | NM |
Y | 2251X0800X | Physical Therapist - Orthopedic | 1012 | NM |
NPI | 1073591095 |
---|---|
Provider Name | Jacobus G Vanzelst |
First Address | Albuquerque, NM 87106-4917 |
Second Address | Rio Rancho, NM 87124 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2006 |
Last Update Date | 25/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
48677876 | (05) | NM |