Basic Information
| Provider Information | |||||||||
| NPI: | 1073138434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | GAGE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 PRESIDENTS DR | ||||||||
| Address2: | |||||||||
| City: | HUMMELSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170368621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178392188 | ||||||||
| FaxNumber: | 7175651104 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 STEVE BARRY BLVD | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743616841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188244500 | ||||||||
| FaxNumber: | 9188241977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2020 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5808 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.