Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 1165213 | TX |
NPI | 1104306257 |
---|---|
Provider Name | Jissa Thayil |
First Address | Georgetown, TX 78626-7684 |
Second Address | Georgetown, TX 78626-7684 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2018 |
Last Update Date | 17/08/2018 |