Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 083026 | IA |
NPI | 1013464650 |
---|---|
Provider Name | Ms. Krystal Wilson |
First Address | Toledo, IA 52342 |
Second Address | Toledo, IA 52342-2307 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2016 |
Last Update Date | 01/09/2016 |