Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PTA30943 | FL |
Y | 213ES0000X | Sports Medicine | PTA30943 | FL |
NPI | 1285211847 |
---|---|
Provider Name | Javonte Fredericks |
First Address | Altamonte Springs, FL 32701-2240 |
Second Address | Altamonte Springs, FL 32701-2240 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2021 |
Last Update Date | 28/03/2021 |