Provider Demographics
NPI:1245807551
Name:ANDERSON, MILES (PTA)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:ANDERSON
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 1:3677 HIGHLAND FAIRWAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-5763
Mailing Address - Country:US
Mailing Address - Phone:517-803-3424
Mailing Address - Fax:
Practice Address - Street 1:710 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4938
Practice Address - Country:US
Practice Address - Phone:888-699-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2021-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28673225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant