Basic Information
| Provider Information | |||||||||
| NPI: | 1306430277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONZMAN | ||||||||
| FirstName: | MICHAELA | ||||||||
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| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708429323 | ||||||||
| FaxNumber: | 5705871978 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 GROW AVE | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188011105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702781101 | ||||||||
| FaxNumber: | 5702781102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2021 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT029315 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT029315 | 01 | PA | DEPARTMENT OF STATE | OTHER |