Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 1122265 | TX |
NPI | 1023029568 |
---|---|
Provider Name | Ms. Norma R Antedomenico |
First Address | Pottsboro, TX 75076-3809 |
Second Address | Pottsboro, TX 75076-3809 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2006 |
Last Update Date | 17/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
456619 | MEDICARE PTAN (01) | TX |
8T4408 | BLUE CROSS PROVIDER NUMBE (01) | TX |