Provider Demographics
NPI:1891192381
Name:MOTTRAM, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MOTTRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41125 N DAISY MOUNTAIN DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-4954
Mailing Address - Country:US
Mailing Address - Phone:623-551-9706
Mailing Address - Fax:623-551-5078
Practice Address - Street 1:9784 W YEARLING RD
Practice Address - Street 2:BUILDING B, SUITE 1520
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1379
Practice Address - Country:US
Practice Address - Phone:623-412-2117
Practice Address - Fax:623-412-2118
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist