Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT.011095 | OH |
N | 2251X0800X | Physical Therapist - Orthopedic | PT.004781 | KY |
NPI | 1053389114 |
---|---|
Provider Name | Mr. Patrick Raymond Mckibben |
First Address | Cincinnati, OH 45242-8398 |
Second Address | Cincinnati, OH 45245-1318 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 01/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000502323 | ANTHEM (01) | OH |
2750545 | (05) | OH |