MEDICARE: MS. TRISA JOB P.T.

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	32381	FL
2	225100000X	Physical Therapist	028431	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720147226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRISA JOB P.T.

Provider Business Mailing Address
First Line	:	35902 HWY 27
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3737
Country	:	US
Telephone Number	:	863-421-1777
Fax Number	:	863-421-7070

Provider Business Practice Location Address
First Line	:	35902 HWY 27
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-3737
Country	:	US
Telephone Number	:	863-421-1777
Fax Number	:	863-421-7070

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

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	03/17/2018

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