Provider Demographics
NPI:1043691298
Name:PERDUE, JOSEPH JONATHAN (PTA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JONATHAN
Last Name:PERDUE
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 1:6792 DULCE REAL
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34951-4406
Mailing Address - Country:US
Mailing Address - Phone:772-708-4785
Mailing Address - Fax:
Practice Address - Street 1:6792 DULCE REAL
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34951-4406
Practice Address - Country:US
Practice Address - Phone:772-708-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2015-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21868225200000X
CA9486225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant