Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 1111524 | TX |
Y | 2251X0800X | Physical Therapist - Orthopedic | 1111524 | TX |
NPI | 1053470567 |
---|---|
Provider Name | Paul James Hendricks |
First Address | Lakeway, TX 78734-3840 |
Second Address | Lakeway, TX 78734-5160 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2006 |
Last Update Date | 29/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1111524 | STATE PT LICENSE (01) | TX |