Provider Demographics
NPI:1467594606
Name:DURHAM, GREG J (PTA)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:J
Last Name:DURHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14810 NASHWA ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1151
Mailing Address - Country:US
Mailing Address - Phone:210-471-1216
Mailing Address - Fax:210-858-4047
Practice Address - Street 1:3355 CHERRY RIDGE ST STE 209
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4818
Practice Address - Country:US
Practice Address - Phone:210-366-1575
Practice Address - Fax:210-366-1883
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX2058320225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant