Provider Demographics
NPI:1831433325
Name:EXETER, GEORGE KENYON (PTA)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:KENYON
Last Name:EXETER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:EXETER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:24 G ST NE
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1769
Mailing Address - Country:US
Mailing Address - Phone:509-754-5516
Mailing Address - Fax:
Practice Address - Street 1:817 E PLUM AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837
Practice Address - Country:US
Practice Address - Phone:509-765-7835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60100220225200000X
IDPTA-51225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant