Healthcare Provider Details

I. General information

NPI: 1073031274
Provider Name (Legal Business Name): DAVID REPP PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 N FIGHTER COUNTRY AVE
LUKE AFB AZ
85309-1636
US

IV. Provider business mailing address

7010 N FIGHTER COUNTRY AVE
LUKE AFB AZ
85309-1636
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-4046
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13326PT
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: