Provider Demographics
NPI:1992213219
Name:GOLTRY, IRENE ANNE (PTA)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ANNE
Last Name:GOLTRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LAKE BAYSHORE DRIVE
Mailing Address - Street 2:303
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-9038
Mailing Address - Country:US
Mailing Address - Phone:941-580-1318
Mailing Address - Fax:
Practice Address - Street 1:1959 N HONORE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-9117
Practice Address - Country:US
Practice Address - Phone:941-379-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA2278225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant