Basic Information
| Provider Information | |||||||||
| NPI: | 1366657934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TJAN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1374 E CENTURY AVE | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852961302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805032718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7255 E BROADWAY RD | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852089201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809818844 | ||||||||
| FaxNumber: | 4809816998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3090 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.