Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 004563 | KY |
NPI | 1992795777 |
---|---|
Provider Name | William Joseph Blackburn |
First Address | Cincinnati, OH 45270-6031 |
Second Address | Edgewood, KY 41017 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2005 |
Last Update Date | 29/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8700133500 | (05) | KY |