Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 10800 | MN |
NPI | 1063930493 |
---|---|
Provider Name | Thomas Broback |
First Address | Rosemount, MN 55068-3671 |
Second Address | Stillwater, MN 55082-6311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2017 |
Last Update Date | 20/02/2020 |