Provider Demographics
NPI:1285915140
Name:EUSEBIO, GERARD SANTOS (PTA)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:SANTOS
Last Name:EUSEBIO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1083
Mailing Address - Country:US
Mailing Address - Phone:330-430-2119
Mailing Address - Fax:330-452-1739
Practice Address - Street 1:800 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1083
Practice Address - Country:US
Practice Address - Phone:330-430-2119
Practice Address - Fax:330-452-1739
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA-5100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant