Basic Information
| Provider Information | |||||||||
| NPI: | 1639712433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MPT, OCS, SCS, MTC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585543711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15004 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921283491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589275527 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2019 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | PT22963 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.