Provider Demographics
NPI:1508016049
Name:CAPUYAN, EDWIN REQUILLO (PT)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:REQUILLO
Last Name:CAPUYAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5523 STONEHILL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-4199
Mailing Address - Country:US
Mailing Address - Phone:260-579-8634
Mailing Address - Fax:
Practice Address - Street 1:5523 STONEHILL CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-4199
Practice Address - Country:US
Practice Address - Phone:260-579-8634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-21
Last Update Date:2008-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004058A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist