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Federal employer tax ID Organization
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Organization Name
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Name Facility
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National provider ID:ID:Pt:Provider:Nom:
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Provider Last name
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Provider First name
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Middle name Provider
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Sex of Provider
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Birth Date Provider
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{mm/dd/yyyy}
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Provider race OMB.1997
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Provider ethnicity OMB.1997
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Provider Grad year
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{yyyy}
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Grad state Provider
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PT provider type APTA
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PT Prov entry-level degree
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PT Prov highest educ
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PT provider residency or fellowship APTA
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PT provider specialty APTA
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