Healthcare Provider Details

I. General information

NPI: 1306674395
Provider Name (Legal Business Name): SONY WALSER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7540 W UNIVERSITY AVE
GAINESVILLE FL
32607-7609
US

IV. Provider business mailing address

3334 CAPITAL MEDICAL BLVD
TALLAHASSEE FL
32308-8405
US

V. Phone/Fax

Practice location:
  • Phone: 352-647-9700
  • Fax:
Mailing address:
  • Phone: 850-877-8174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL597
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20120
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: