Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | TEI003609 | PA |
NPI | 1003297094 |
---|---|
Provider Name | Mr. Kyle Campbell |
First Address | East Stroudsburg, PA 18301-9720 |
Second Address | East Stroudsburg, PA 18301-9720 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2015 |
Last Update Date | 15/06/2015 |