Provider Demographics
NPI:1144726043
Name:MISSETT, THOMAS ROBERT
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:MISSETT
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 1:8380 CENTER DR STE E
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2952
Mailing Address - Country:US
Mailing Address - Phone:619-466-6077
Mailing Address - Fax:
Practice Address - Street 1:8380 CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2952
Practice Address - Country:US
Practice Address - Phone:619-466-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA49143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant