Healthcare Provider Details

I. General information

NPI: 1326533001
Provider Name (Legal Business Name): BRANDON HAGEROTT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 W TOWN PKWY
ALTAMONTE SPRINGS FL
32714-3845
US

IV. Provider business mailing address

2334 AUDLEY ST
OVIEDO FL
32765-7690
US

V. Phone/Fax

Practice location:
  • Phone: 407-865-8000
  • Fax:
Mailing address:
  • Phone: 772-643-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28402
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: