Provider Demographics
NPI:1851599732
Name:TOLBERT, CORDERO SHAWN (PTA)
Entity Type:Individual
Prefix:MR
First Name:CORDERO
Middle Name:SHAWN
Last Name:TOLBERT
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 1:4693 BISON ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4135
Mailing Address - Country:US
Mailing Address - Phone:561-541-8621
Mailing Address - Fax:
Practice Address - Street 1:4693 BISON ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-4135
Practice Address - Country:US
Practice Address - Phone:561-541-8621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20819225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant