Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 25182 | CA |
NPI | 1306200753 |
---|---|
Provider Name | Matthew Tyner |
First Address | Angwin, CA 94508-9746 |
Second Address | Angwin, CA 94508-9746 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2016 |
Last Update Date | 12/04/2016 |