MEDICARE: ZACKERY LAYNE BURKHOLDER 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	PTA25917	FL

General Provider Information

NPI Number	:	1720454085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACKERY LAYNE BURKHOLDER PTA

Provider Business Mailing Address
First Line	:	11706 CROWNED SPARROW LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-2650
Country	:	US
Telephone Number	:	863-832-3312
Fax Number	:

Provider Business Practice Location Address
First Line	:	12705 RACE TRACK RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1314
Country	:	US
Telephone Number	:	813-343-3960
Fax Number	:

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

Provider Enumeration Date	:	08/20/2015
Last Update Date	:	03/07/2025

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