Provider Demographics
NPI:1710259619
Name:VERGARA, YANETH D (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:YANETH
Middle Name:D
Last Name:VERGARA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 50TH AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210
Mailing Address - Country:US
Mailing Address - Phone:608-758-9560
Mailing Address - Fax:
Practice Address - Street 1:4625 50TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-2981
Practice Address - Country:US
Practice Address - Phone:608-758-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2251P0200XMedicaid