Healthcare Provider Details

I. General information

NPI: 1821411141
Provider Name (Legal Business Name): ANGELINA PUA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 11/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7675 FAMILY CIR
SAN DIEGO CA
92111-5304
US

IV. Provider business mailing address

7675 FAMILY CIR
SAN DIEGO CA
92111-5304
US

V. Phone/Fax

Practice location:
  • Phone: 858-278-8121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number29139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: