Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT12294 | CA |
NPI | 1073557708 |
---|---|
Provider Name | Marilyn Staroba Johnson |
First Address | San Diego, CA 92108-3118 |
Second Address | San Diego, CA 92108-3118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2006 |
Last Update Date | 13/08/2014 |