=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205360583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY WOERNER DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2017
-----------------------------------------------------
Last Update Date | 01/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 W BRIGANTINE AVE
-----------------------------------------------------
City | BRIGANTINE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08203-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-264-1666
-----------------------------------------------------
Fax | 609-264-8393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3201 W BRIGANTINE AVE
-----------------------------------------------------
City | BRIGANTINE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08203-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-264-1666
-----------------------------------------------------
Fax | 609-264-8393
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01833500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------