MEDICARE: MS. DIANA BAKLE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA006942	OH

General Provider Information

NPI Number	:	1275061913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA BAKLE PTA

Provider Business Mailing Address
First Line	:	PO BOX 101
Second Line	:
City	:	WAPAKONETA
State	:	OH
Zip	:	45895-0101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 N DIXIE HWY
Second Line	:
City	:	WAPAKONETA
State	:	OH
Zip	:	45895-7739
Country	:	US
Telephone Number	:	419-738-9675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2017
Last Update Date	:	05/25/2017

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