Provider Demographics
NPI:1114455458
Name:PHAN, TOM LONG HOANG (DPT PT)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:LONG HOANG
Last Name:PHAN
Suffix:
Gender:M
Credentials:DPT PT
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Mailing Address - Street 1:4539 S DALE MABRY HWY
Mailing Address - Street 2:STE 110
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1404
Mailing Address - Country:US
Mailing Address - Phone:904-829-3411
Mailing Address - Fax:904-829-3412
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5799
Practice Address - Country:US
Practice Address - Phone:904-829-3411
Practice Address - Fax:904-829-3412
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPT32562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist