Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 50546 | CA |
NPI | 1003427006 |
---|---|
Provider Name | Travis Wade Shaffer |
First Address | Ceres, CA 95307-2800 |
Second Address | Ceres, CA 95307-2800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2020 |
Last Update Date | 09/01/2022 |