Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 004861 | IA |
N | 225200000X | Physical Therapy Assistant | 1107 | NE |
NPI | 1003219973 |
---|---|
Provider Name | Kelly Buckman |
First Address | Council Bluffs, IA 51503-9004 |
Second Address | Council Bluffs, IA 51503-9004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2014 |
Last Update Date | 06/10/2014 |