=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437673183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONYA PEREZ PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2017
-----------------------------------------------------
Last Update Date | 08/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3452 LAKE LYNDA DR STE 200
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-1481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-308-3852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3106 8TH ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-701-6576
-----------------------------------------------------
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 | P160653402
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------