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General NPI Number Information
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NPI Number | 1508078130
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Entity Type | Individual
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Provider Name | JONATHAN MULLIS PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 701 MANATEE AVE W
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City | BRADENTON
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State | FL
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Zip | 34205-8604
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Country | US
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Telephone | 617-519-6443
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Fax |
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Provider Business Mailing Address
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Address Line | 13803 SWIFTWATER WAY
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City | BRADENTON
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State | FL
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Zip | 34211-4084
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Country | US
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Telephone | 617-519-6443
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 15359
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT32979
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License Number State | FL
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