Provider Demographics
NPI:1831493154
Name:ISHIZAWA, MAIKO (PTA)
Entity Type:Individual
Prefix:MS
First Name:MAIKO
Middle Name:
Last Name:ISHIZAWA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:MAIKO
Other - Middle Name:
Other - Last Name:DECLET-ISHIZAWA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5347 ALCOLA WAY S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-4929
Mailing Address - Country:US
Mailing Address - Phone:727-637-6293
Mailing Address - Fax:727-374-7255
Practice Address - Street 1:5347 ALCOLA WAY S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-4929
Practice Address - Country:US
Practice Address - Phone:727-637-6293
Practice Address - Fax:727-374-7255
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant