Healthcare Provider Details

I. General information

NPI: 1114382041
Provider Name (Legal Business Name): JUNKO STEWART PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2907 W BAY TO BAY BLVD SUITE 100
TAMPA FL
33629-1706
US

IV. Provider business mailing address

2907 W BAY TO BAY BLVD SUITE 100
TAMPA FL
33629-1706
US

V. Phone/Fax

Practice location:
  • Phone: 813-250-1208
  • Fax: 813-250-1209
Mailing address:
  • Phone: 813-250-1208
  • Fax: 813-250-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: