Healthcare Provider Details

I. General information

NPI: 1831393446
Provider Name (Legal Business Name): HEATHER MARIE BACON-PUTIRKA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 E NEES AVE 150
FRESNO CA
93760-2268
US

IV. Provider business mailing address

3400 CALLOWAY DR STE 603
BAKERSFIELD CA
93312-2514
US

V. Phone/Fax

Practice location:
  • Phone: 661-377-1700
  • Fax: 661-616-9199
Mailing address:
  • Phone: 661-377-1700
  • Fax: 661-616-9199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT22814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: