=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083186589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR JOHN VISSERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2018
-----------------------------------------------------
Last Update Date | 12/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 OSPREY VILLAGE DR
-----------------------------------------------------
City | FERNANDINA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-277-8222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55246 LITTLE BROOK DR
-----------------------------------------------------
City | CALLAHAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32011-5595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-629-9678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA28773
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------