Provider Demographics
NPI:1609149244
Name:WATTERSON, BRENT MCKINLEY (PTA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:MCKINLEY
Last Name:WATTERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6015 POINTE WEST BLVD
Mailing Address - Street 2:COASTAL ORTHOPEDICS AND SPORTS MEDICINE, ATTN CREDENTIA
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5542
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-296-7662
Practice Address - Street 1:6015 POINTE WEST BLVD
Practice Address - Street 2:COASTAL ORTHOPEDICS AND SPORTS MEDICINE, ATTN CREDENTIA
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5542
Practice Address - Country:US
Practice Address - Phone:941-792-1404
Practice Address - Fax:941-296-7662
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21781225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant