Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 11925A | AZ |
NPI | 1003271685 |
---|---|
Provider Name | Justin Rodriguez |
First Address | Chino Valley, AZ 86323-5943 |
Second Address | Chino Valley, AZ 86323-5943 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/12/2015 |
Last Update Date | 23/12/2015 |