Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA5569 | CA |
NPI | 1013455542 |
---|---|
Provider Name | Thomas B Kelly |
First Address | La Mesa, CA 91942-3806 |
Second Address | La Mesa, CA 91942-3806 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2017 |
Last Update Date | 03/02/2017 |