Provider Demographics
NPI:1588098883
Name:DELA CRUZ, JAN PAUL
Entity type:Individual
Prefix:
First Name:JAN PAUL
Middle Name:
Last Name:DELA CRUZ
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 1:1014 MIDDLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SEVIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37862-2939
Mailing Address - Country:US
Mailing Address - Phone:865-453-9022
Mailing Address - Fax:865-453-9177
Practice Address - Street 1:1014 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-2939
Practice Address - Country:US
Practice Address - Phone:865-453-9022
Practice Address - Fax:865-453-9177
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT010590225100000X
TN9538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist