=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902432131
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTINE RODRIGUEZ PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2020
-----------------------------------------------------
Last Update Date | 03/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 174TH ST NE
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98271-4743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-454-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31506 64TH AVE NW
-----------------------------------------------------
City | STANWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98292-7121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-421-6797
-----------------------------------------------------
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 | P160164694
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------