Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT291895 | CA |
NPI | 1023563954 |
---|---|
Provider Name | Jason Anthony Martins La Rosa |
First Address | San Jose, CA 95127-1102 |
Second Address | Redwood City, CA 94062-1510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2016 |
Last Update Date | 21/08/2016 |