Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA27155 | FL |
NPI | 1013453984 |
---|---|
Provider Name | Stephen Dodge |
First Address | Homosassa, FL 34446-5028 |
Second Address | Homosassa, FL 34446-5028 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2017 |
Last Update Date | 16/01/2017 |