Provider Demographics
NPI:1407696701
Name:IMSON, ROBERTO ANTONIO YUSON (PT)
Entity type:Individual
Prefix:
First Name:ROBERTO ANTONIO
Middle Name:YUSON
Last Name:IMSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 ALBANY PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8805
Mailing Address - Country:US
Mailing Address - Phone:910-619-6079
Mailing Address - Fax:
Practice Address - Street 1:8801 J M KEYNES DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5473
Practice Address - Country:US
Practice Address - Phone:910-619-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP10797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist