Provider Demographics
NPI:1558071084
Name:MCKINNON, CARTER (PTA)
Entity Type:Individual
Prefix:
First Name:CARTER
Middle Name:
Last Name:MCKINNON
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 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0915
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6185
Practice Address - Street 1:1615 PASADENA AVE S STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4518
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6185
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant