Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1234176 | TX |
N | 2251X0800X | Physical Therapist - Orthopedic | 3113552 | TX |
NPI | 1073947933 |
---|---|
Provider Name | Mr. Trey Dulaney |
First Address | Fort Worth, TX 76108-8320 |
Second Address | Fort Worth, TX 76132-4103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2013 |
Last Update Date | 18/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
192079501 | (05) | TX |
45-6752 | MEDICARE FACILITY ID (01) | TX |