Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 8604 | CO |
NPI | 1407027907 |
---|---|
Provider Name | Russell Overy |
First Address | Boulder, CO 80304-3979 |
Second Address | Boulder, CO 80304-3979 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2008 |
Last Update Date | 12/03/2008 |