MEDICARE: MICA SANON RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT014119	GA
2	225100000X	Physical Therapist	10185	SC

General Provider Information

NPI Number	:	1033704267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICA SANON RPT

Provider Business Mailing Address
First Line	:	21 WINSLOW CIR
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31407-4946
Country	:	US
Telephone Number	:	816-898-4227
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 CASSIDY DR
Second Line	:
City	:	BLUFFTON
State	:	SC
Zip	:	29910-4143
Country	:	US
Telephone Number	:	843-396-1065
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	10/13/2025

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Directions to “ MICA SANON RPT” Practice Location

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