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NPI Code Detail

MEDICARE: GREG SCOTT GORHAM PTA

MEDICARE: GREG SCOTT GORHAM 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
1225200000XPhysical Therapy Assistant

General Provider Information

NPI Number : 1780165928
Entity Type Code : Individual
Provider Name (Legal Business Name) : GREG SCOTT GORHAM PTA
Provider Business Mailing Address
First Line : 12811 EL MARRO ST
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78233-5833
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7700 MESQUITE PASS
Second Line :
City : CONVERSE
State : TX
Zip : 78109-2461
Country : US
Telephone Number : 210-650-0551
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/26/2018
Last Update Date : 08/26/2018

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