MEDICARE: STEVEN DISTEFANO PA

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	PTA14688	FL

General Provider Information

NPI Number	:	1780628529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN DISTEFANO PA

Provider Business Mailing Address
First Line	:	6749 LAS COLINAS ST
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-6566
Country	:	US
Telephone Number	:	561-641-4727
Fax Number	:	561-641-4455

Provider Business Practice Location Address
First Line	:	4895 WINDWARD PASSAGE DR
Second Line	:	ST. #3
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-7741
Country	:	US
Telephone Number	:	561-736-9899
Fax Number	:	561-736-2483

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STEVEN ALEXANDER DISTEFANO
Credential	:	PTA
Telephone Number	:	561-736-9899

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/22/2020

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