Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA-4520 | ID |
NPI | 1003382276 |
---|---|
Provider Name | Joel Cruz |
First Address | Wilsonville, OR 97070-9697 |
Second Address | Pocatello, ID 83201-2727 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/10/2018 |
Last Update Date | 16/10/2018 |