Provider Demographics
NPI:1396045381
Name:RODRIGUEZ, JOHN JOSPEH (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSPEH
Last Name:RODRIGUEZ
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:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:SOUTH MOUNTAIN
Mailing Address - State:PA
Mailing Address - Zip Code:17261-0078
Mailing Address - Country:US
Mailing Address - Phone:717-749-5460
Mailing Address - Fax:
Practice Address - Street 1:3640 CORLS RIDGE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:PA
Practice Address - Zip Code:17222-9615
Practice Address - Country:US
Practice Address - Phone:717-749-5460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1383225200000X
PATE1000405225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant