Provider Demographics
NPI:1174717888
Name:ROBERTSON, MATTHEW JOEL (PTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOEL
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 SW SHADY LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3651
Mailing Address - Country:US
Mailing Address - Phone:386-758-8952
Mailing Address - Fax:
Practice Address - Street 1:587 SE ERMINE AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6126
Practice Address - Country:US
Practice Address - Phone:386-754-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20529225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant