MEDICARE: MRS. GENA MCCORMICK PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	AT10777	CA

General Provider Information

NPI Number	:	1184086829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GENA MCCORMICK PTA

Provider Business Mailing Address
First Line	:	1757 GREEN VALLEY RD
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94526-1533
Country	:	US
Telephone Number	:	925-336-1386
Fax Number	:

Provider Business Practice Location Address
First Line	:	1757 GREEN VALLEY RD
Second Line	:
City	:	DANVILLE
State	:	CA
Zip	:	94526-1533
Country	:	US
Telephone Number	:	925-336-1386
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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