Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5191-024 | WI |
N | 2251G0304X | Physical Therapist - Geriatrics | 5191-024 | WI |
NPI | 1396967501 |
---|---|
Provider Name | Mr. Craig M Gorst |
First Address | Oshkosh, WI 54901-1706 |
Second Address | Weyauwega, WI 54983-9024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2007 |
Last Update Date | 09/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
40260200 | (05) | WI |