Provider Demographics
NPI:1649774027
Name:MUSSA, JOHAN SAMIR (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:SAMIR
Last Name:MUSSA
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 PARK EDEN CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-1903
Mailing Address - Country:US
Mailing Address - Phone:787-361-2019
Mailing Address - Fax:
Practice Address - Street 1:11500 FENWAY SOUTH DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-9830
Practice Address - Country:US
Practice Address - Phone:877-733-7699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32152255A2300X
FL67842255A2300X
NY0042742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer