Provider Demographics
NPI:1821781451
Name:EDRIS, KANJO (DPT)
Entity Type:Individual
Prefix:
First Name:KANJO
Middle Name:
Last Name:EDRIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 MID ATLANTIC DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4298
Mailing Address - Country:US
Mailing Address - Phone:394-296-9898
Mailing Address - Fax:
Practice Address - Street 1:5007 MID ATLANTIC DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4298
Practice Address - Country:US
Practice Address - Phone:394-296-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT002695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist