MEDICARE: CASEY MICHAEL MCNEILL PTA

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	225200000X	Physical Therapy Assistant	PTA23708	FL

General Provider Information

NPI Number	:	1366932634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY MICHAEL MCNEILL PTA

Provider Business Mailing Address
First Line	:	2054 PARK ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-3810
Country	:	US
Telephone Number	:	352-895-4854
Fax Number	:

Provider Business Practice Location Address
First Line	:	2054 PARK ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-3810
Country	:	US
Telephone Number	:	352-895-4854
Fax Number	:

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

Provider Enumeration Date	:	05/13/2018
Last Update Date	:	05/13/2018

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