Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 2986 | WI |
NPI | 1003178807 |
---|---|
Provider Name | Mark Scott Herbert |
First Address | Shawano, WI 54166-6130 |
Second Address | Shawano, WI 54166-6130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2012 |
Last Update Date | 08/06/2012 |