Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT014813 | GA |
N | 2251N0400X | Physical Therapist - Neurology | ||
N | 2251S0007X | Physical Therapist - Sports | ||
N | 2251X0800X | Physical Therapist - Orthopedic |
NPI | 1457027732 |
---|---|
Provider Name | Tyler Randolph |
First Address | Sandy Springs, GA 30328-5490 |
Second Address | Atlanta, GA 30318-5713 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2021 |
Last Update Date | 01/09/2021 |