Healthcare Provider Details

I. General information

NPI: 1518312099
Provider Name (Legal Business Name): DOUGLAS YACKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 MARYLAND RD STE 250
WILLOW GROVE PA
19090-1133
US

IV. Provider business mailing address

2510 MARYLAND RD STE 250
WILLOW GROVE PA
19090-1133
US

V. Phone/Fax

Practice location:
  • Phone: 215-481-5884
  • Fax: 215-481-5986
Mailing address:
  • Phone: 215-481-5884
  • Fax: 215-481-5986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005621L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: