Provider Demographics
NPI:1275097669
Name:PUPO, RAQUEL B (PTA)
Entity Type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:B
Last Name:PUPO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 BAY RUN ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4006
Mailing Address - Country:US
Mailing Address - Phone:954-740-2520
Mailing Address - Fax:
Practice Address - Street 1:2520 N ORANGE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4638
Practice Address - Country:US
Practice Address - Phone:954-740-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant