Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | A-0832 | NV |
NPI | 1003277484 |
---|---|
Provider Name | Travis Grondel |
First Address | North Las Vegas, NV 89031-5111 |
Second Address | Las Vegas, NV 89102-1859 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2016 |
Last Update Date | 14/03/2016 |