Provider Demographics
NPI:1851966535
Name:BALTAR, DYLAN JORDAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:JORDAN
Last Name:BALTAR
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 1:430 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-5688
Mailing Address - Country:US
Mailing Address - Phone:954-496-3110
Mailing Address - Fax:
Practice Address - Street 1:430 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5688
Practice Address - Country:US
Practice Address - Phone:954-496-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31008225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant