Provider Demographics
NPI:1881940757
Name:FEMINO, GINA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:FEMINO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6032 N GADWALL LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1284
Mailing Address - Country:US
Mailing Address - Phone:208-484-0143
Mailing Address - Fax:
Practice Address - Street 1:524 CLEVELAND BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4079
Practice Address - Country:US
Practice Address - Phone:208-455-5010
Practice Address - Fax:208-455-5020
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-3051225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant