Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2158925 | TX |
NPI | 1003407602 |
---|---|
Provider Name | Justin Lyons |
First Address | Waco, TX 76712-8834 |
Second Address | Waco, TX 76712-8834 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2021 |
Last Update Date | 27/01/2021 |