Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 2014021748 | MO |
NPI | 1447652540 |
---|---|
Provider Name | Jay L Maturan |
First Address | Saint Louis, MO 63119-1917 |
Second Address | Warrenton, MO 63383-2127 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2014 |
Last Update Date | 19/09/2014 |