Provider Demographics
NPI:1164895447
Name:JAMOTUYA, REYSAN
Entity Type:Individual
Prefix:
First Name:REYSAN
Middle Name:
Last Name:JAMOTUYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7710 FORT GRIFFIN DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-5783
Mailing Address - Country:US
Mailing Address - Phone:361-343-1362
Mailing Address - Fax:
Practice Address - Street 1:7710 FORT GRIFFIN DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-5783
Practice Address - Country:US
Practice Address - Phone:361-343-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182130225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1182130OtherPT LICENSE NUMBER