Individual
CLINTON AXMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
128 5TH AVE W, JEROME, ID 83338-1863
(208) 324-3090
(208) 324-3093
Mailing address
128 5TH AVE W, JEROME, ID 83338-1863
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2915
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PENDING
MEDICARE
ID
05
—
PENDING
—
ID
Enumeration date
09/15/2011
Last updated
09/15/2011
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