Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2112757 | TX |
NPI | 1003291485 |
---|---|
Provider Name | Kassandra Gonzalez |
First Address | Laredo, TX 78041-5434 |
Second Address | Laredo, TX 78041-5434 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2015 |
Last Update Date | 27/07/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2112757 | STATE LICENSE (01) | TX |