Provider Demographics
NPI:1790454049
Name:KHAYAT, SAMEH (PTA)
Entity Type:Individual
Prefix:
First Name:SAMEH
Middle Name:
Last Name:KHAYAT
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 1:8180 PRESLEY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0079
Mailing Address - Country:US
Mailing Address - Phone:904-405-3605
Mailing Address - Fax:
Practice Address - Street 1:4101 SOUTHPOINT DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0996
Practice Address - Country:US
Practice Address - Phone:904-296-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31227225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant