Basic Information
Provider Information | |||||||||
NPI: | 1629532130 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ESPINA | ||||||||
FirstName: | SIDNEY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4100 WEEKS PARK LN APT 215 | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763083250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9408677700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1101 GRACE ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763014414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9407206633 | ||||||||
FaxNumber: | 9407661650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2019 | ||||||||
LastUpdateDate: | 01/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
ID Information
ID | Type | State | Issuer | Description | 1204159 | 01 | TX | TEXAS BOARD OF PHYSICAL THERAPY EXAMINERS | OTHER |