Provider Demographics
NPI:1942428156
Name:ABRAHAM, KANJIRATHUMMOOTTIL KURUVILLA (PTA)
Entity Type:Individual
Prefix:MR
First Name:KANJIRATHUMMOOTTIL
Middle Name:KURUVILLA
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2002 DUMONT DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7192
Mailing Address - Country:US
Mailing Address - Phone:813-782-3959
Mailing Address - Fax:813-780-2569
Practice Address - Street 1:6330 FORT KING RD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542-2531
Practice Address - Country:US
Practice Address - Phone:813-782-3959
Practice Address - Fax:813-780-2569
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA0690225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant