Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 070009093 | IL |
NPI | 1336445170 |
---|---|
Provider Name | Wanasinghe Jayasena |
First Address | Northfield, IL 60093-2757 |
Second Address | Northfield, IL 60093-2757 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2011 |
Last Update Date | 26/01/2011 |