Provider Demographics
NPI:1568524304
Name:TANAKA, MIKIO (PT)
Entity Type:Individual
Prefix:MR
First Name:MIKIO
Middle Name:
Last Name:TANAKA
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 1:39400 PASEO PADRE PKWY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2310
Mailing Address - Country:US
Mailing Address - Phone:510-248-3015
Mailing Address - Fax:510-248-3212
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-248-3015
Practice Address - Fax:510-248-3212
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22809225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist