Provider Demographics
NPI:1053079970
Name:ROBERTSON, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2839 SW 87TH DR STE 10
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9376
Mailing Address - Country:US
Mailing Address - Phone:352-505-6665
Mailing Address - Fax:
Practice Address - Street 1:2839 SW 87TH DR STE 10
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9376
Practice Address - Country:US
Practice Address - Phone:352-505-6665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA31569OtherPTA LICENSE