MEDICARE: MRS. LISA WHITTAKER 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	PTA937	FL

General Provider Information

NPI Number	:	1386778207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA WHITTAKER PTA

Provider Business Mailing Address
First Line	:	25240 ROLLING OAK RD
Second Line	:
City	:	SORRENTO
State	:	FL
Zip	:	32776-8764
Country	:	US
Telephone Number	:	352-383-5473
Fax Number	:	352-357-5428

Provider Business Practice Location Address
First Line	:	25240 ROLLING OAK RD
Second Line	:
City	:	SORRENTO
State	:	FL
Zip	:	32776-8764
Country	:	US
Telephone Number	:	352-383-5473
Fax Number	:	352-357-5428

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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