Healthcare Provider Details

I. General information

NPI: 1295923399
Provider Name (Legal Business Name): ANTHONY MARK STAFFA ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 VINELAND RD SUITE 304
ORLANDO FL
32819-7800
US

IV. Provider business mailing address

5979 VINELAND RD SUITE 304
ORLANDO FL
32819-7800
US

V. Phone/Fax

Practice location:
  • Phone: 407-354-3906
  • Fax: 407-354-3907
Mailing address:
  • Phone: 407-354-3906
  • Fax: 407-354-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL #2292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: