Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MT-22818 | AZ |
NPI | 1013415025 |
---|---|
Provider Name | Sara Elizabeth Bossom |
First Address | Tucson, AZ 85716-1912 |
Second Address | Tucson, AZ 85716-1912 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2018 |
Last Update Date | 24/01/2018 |