Provider Demographics
NPI:1558933010
Name:TAGUBAR, KEVIN PATRICK (PTA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PATRICK
Last Name:TAGUBAR
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 1:3624 WHISPER CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3490
Mailing Address - Country:US
Mailing Address - Phone:904-449-3436
Mailing Address - Fax:
Practice Address - Street 1:3624 WHISPER CREEK BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3490
Practice Address - Country:US
Practice Address - Phone:904-449-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30041225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty