Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 3514 | NC |
NPI | 1003949116 |
---|---|
Provider Name | Ms. Tonya Theresa Mack |
First Address | Matthews, NC 28105-1608 |
Second Address | Pineville, NC 28134-9327 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2007 |
Last Update Date | 08/07/2007 |