Healthcare Provider Details

I. General information

NPI: 1467169664
Provider Name (Legal Business Name): ISAIAH ELIJAH ASPRA REQUINTINA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 10/28/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6258 CR-453
PENSACOLA FL
32505
US

IV. Provider business mailing address

4624 CROSSINGS COURT APT. 201
PACE FL
32571
US

V. Phone/Fax

Practice location:
  • Phone: 850-904-4344
  • Fax:
Mailing address:
  • Phone: 903-241-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT39286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: