Provider Demographics
NPI:1447755202
Name:PHAN, TOMMY (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 E 2ND PLZ
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-5626
Mailing Address - Country:US
Mailing Address - Phone:850-319-9596
Mailing Address - Fax:
Practice Address - Street 1:201 N NORTHPARK LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8403
Practice Address - Country:US
Practice Address - Phone:417-623-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist