Healthcare Provider Details

I. General information

NPI: 1396195335
Provider Name (Legal Business Name): MICHAEL TINO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 6TH ST S STE 310
ST PETERSBURG FL
33701-4824
US

IV. Provider business mailing address

1108 MANDARIN DR
HOLIDAY FL
34691-6707
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA22686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: