Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251C2600X | Cardiopulmonary | 40QA00988600 | NJ |
Y | 2251G0304X | Physical Therapist - Geriatrics | 40QA00988600 | NJ |
N | 2251X0800X | Physical Therapist - Orthopedic | 40QA00988600 | NJ |
NPI | 1073629077 |
---|---|
Provider Name | Mrs. Irma Tetruashvily |
First Address | Marlton, NJ 08053-5525 |
Second Address | Marlton, NJ 08053-5525 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2006 |
Last Update Date | 24/01/2011 |