MEDICARE: MR. GARY BOGGS II 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	PTA.10707	OH

General Provider Information

NPI Number	:	1528822442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY BOGGS II PTA

Provider Business Mailing Address
First Line	:	732 PAULA ST
Second Line	:
City	:	VANDALIA
State	:	OH
Zip	:	45377-1153
Country	:	US
Telephone Number	:	937-475-2033
Fax Number	:

Provider Business Practice Location Address
First Line	:	3797 SUMMIT GLEN DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45449-3657
Country	:	US
Telephone Number	:	937-475-2033
Fax Number	:

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

Provider Enumeration Date	:	02/12/2024
Last Update Date	:	02/12/2024

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