Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant |
NPI | 1013549880 |
---|---|
Provider Name | Travis Lee Koehn |
First Address | Lufkin, TX 75904-8812 |
Second Address | Lufkin, TX 75904-7590 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2020 |
Last Update Date | 10/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
020809 | (05) | TX |