Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA 26634 | FL |
NPI | 1003264003 |
---|---|
Provider Name | Mr. Rene Fontanez JR. |
First Address | Orlando, FL 32819-5400 |
Second Address | Orlando, FL 32819-5400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2016 |
Last Update Date | 09/01/2017 |