Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 5287 | ID |
NPI | 1013588169 |
---|---|
Provider Name | Vanessa Anne Gray |
First Address | Meridian, ID 83646-0004 |
Second Address | Meridian, ID 83646-0004 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2021 |
Last Update Date | 08/07/2021 |