Individual
JESSE KUSMULYANA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
103 MEDICINE WAY RD, PERIDOT, AZ 85542-5000
(928) 475-1360
Mailing address
103 MEDICINE WAY RD, PERIDOT, AZ 85542-5000
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA-013887
AZ
Other
Enumeration date
05/29/2019
Last updated
05/29/2019
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