Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA71333 | FL |
NPI | 1013252873 |
---|---|
Provider Name | Mr. Craig F Wathen JR. |
First Address | Tampa, FL 33617-4512 |
Second Address | Tampa, FL 33617-4512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2012 |
Last Update Date | 05/12/2012 |