Provider Demographics
NPI:1720198435
Name:CONRIQUE, PETER A
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:CONRIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55801 BEAR RUN RD
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-8514
Mailing Address - Country:US
Mailing Address - Phone:904-879-9576
Mailing Address - Fax:
Practice Address - Street 1:12961 N MAIN ST
Practice Address - Street 2:SUITE 201 & 202
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2769
Practice Address - Country:US
Practice Address - Phone:904-757-2474
Practice Address - Fax:904-757-5541
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FLPT25868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer