Healthcare Provider Details

I. General information

NPI: 1104771328
Provider Name (Legal Business Name): MATTHEW WATKINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 LAURA ST
STARKE FL
32091-4026
US

IV. Provider business mailing address

13463 SUNSTONE ST
JACKSONVILLE FL
32258-5480
US

V. Phone/Fax

Practice location:
  • Phone: 858-350-3294
  • Fax:
Mailing address:
  • Phone: 904-217-9532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA29030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: