Healthcare Provider Details

I. General information

NPI: 1245807551
Provider Name (Legal Business Name): MILES ANDERSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2021
Last Update Date: 06/06/2021
Certification Date: 06/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 OAKFIELD DR
BRANDON FL
33511-4938
US

IV. Provider business mailing address

3677 HIGHLAND FAIRWAYS BLVD
LAKELAND FL
33810-5763
US

V. Phone/Fax

Practice location:
  • Phone: 888-699-5242
  • Fax:
Mailing address:
  • Phone: 517-803-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number28673
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: