Provider Demographics
NPI:1043366321
Name:TABASKO, MICHAEL DAVID (MSPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:TABASKO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3038
Mailing Address - Country:US
Mailing Address - Phone:818-795-6140
Mailing Address - Fax:
Practice Address - Street 1:2819 3RD ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3038
Practice Address - Country:US
Practice Address - Phone:818-795-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9493225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist