Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 20500 | MD |
Y | 225100000X | Physical Therapist | PT015918 | PA |
NPI | 1003031816 |
---|---|
Provider Name | Mr. James Blakely |
First Address | Indiana, PA 15701-3501 |
Second Address | Philadelphia, PA 19150-1617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 17/02/2016 |