=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801305495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS LETRUD II PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2017
-----------------------------------------------------
Last Update Date | 09/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 4TH ST SE
-----------------------------------------------------
City | ORTONVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-305-1311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 4TH ST SE
-----------------------------------------------------
City | ORTONVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56278-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 0271
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------