Healthcare Provider Details

I. General information

NPI: 1134643356
Provider Name (Legal Business Name): THOMAS MULLIGAN PT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2017
Last Update Date: 07/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CHANNELSIDE DR
TAMPA FL
33602-5400
US

IV. Provider business mailing address

10276 ESTUARY DR
TAMPA FL
33647-3123
US

V. Phone/Fax

Practice location:
  • Phone: 813-301-6793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT23678
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: