Provider Demographics
NPI:1235342676
Name:ROSCOW, AMANDA (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROSCOW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2783 SW 87TH DR STE 102
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9375
Mailing Address - Country:US
Mailing Address - Phone:352-505-6665
Mailing Address - Fax:352-226-8744
Practice Address - Street 1:2783 SW 87TH DR STE 102
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9375
Practice Address - Country:US
Practice Address - Phone:352-505-6665
Practice Address - Fax:352-226-8744
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 19139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY003TOtherBCBS
FLY003TZMedicare ID - Type Unspecified