Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 10367 | CO |
N | 225100000X | Physical Therapist | PT011869 | OH |
NPI | 1003004342 |
---|---|
Provider Name | Mr. Shingo Tanaka |
First Address | Rangely, CO 81648-3105 |
Second Address | Rangely, CO 81648-3105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2007 |
Last Update Date | 10/10/2013 |