Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | 1190952 | TX |
N | 2251X0800X | Physical Therapist - Orthopedic | 1190952 | TX |
NPI | 1497037188 |
---|---|
Provider Name | Kerwin Noel Payabyab Custodio |
First Address | Frisco, TX 75035-8880 |
Second Address | Plano, TX 75093-5323 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2011 |
Last Update Date | 19/09/2011 |