Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251C2600X | Cardiopulmonary | ||
N | 2251G0304X | Physical Therapist - Geriatrics | ||
N | 2251P0200X | Physical Therapist - Pediatrics | ||
N | 2251S0007X | Physical Therapist - Sports | ||
Y | 2251X0800X | Physical Therapist - Orthopedic | PT-3572 | ID |
NPI | 1073115382 |
---|---|
Provider Name | Jordan Stoddard |
First Address | Rigby, ID 83442-5326 |
Second Address | Idaho Falls, ID 83402-3344 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2020 |
Last Update Date | 03/12/2020 |