Healthcare Provider Details

I. General information

NPI: 1174894059
Provider Name (Legal Business Name): ELIZABETH ANN MCGONAGLE DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 SOSCOL AVENUE SUITE B 191
NAPA CA
94559-4040
US

IV. Provider business mailing address

433 SOSCOL AVENUE SUITE B 191
NAPA CA
94559-4040
US

V. Phone/Fax

Practice location:
  • Phone: 707-224-3131
  • Fax: 707-224-2356
Mailing address:
  • Phone: 707-224-3131
  • Fax: 707-224-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT38022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: