Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2016025040 | MO |
NPI | 1013450691 |
---|---|
Provider Name | Logan Gegg |
First Address | Saint Mary, MO 63673-9002 |
Second Address | Saint Mary, MO 63673-9002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2016 |
Last Update Date | 30/11/2016 |