Provider Demographics
NPI:1114462066
Name:MAGGID, MICHAEL (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MAGGID
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 RICHARDSON CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7488
Mailing Address - Country:US
Mailing Address - Phone:707-762-3603
Mailing Address - Fax:
Practice Address - Street 1:1455 RICHARDSON CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7488
Practice Address - Country:US
Practice Address - Phone:707-762-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA3733225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant