Healthcare Provider Details

I. General information

NPI: 1780646703
Provider Name (Legal Business Name): TISHA DAWN SUTTON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52ND MDG/SPANGDAHLEM CLINIC BUILDING 550
APO AE
09123
US

IV. Provider business mailing address

PSC 9 BOX 5936
APO AE
09123-0060
US

V. Phone/Fax

Practice location:
  • Phone: 314-452-8430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3549
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: