Provider Demographics
NPI:1669172201
Name:ROMANENKO, ROMAN (PTA)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:ROMANENKO
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 1:18 PEBBLE BEACH RD
Mailing Address - Street 2:
Mailing Address - City:ROTONDA WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33947-2147
Mailing Address - Country:US
Mailing Address - Phone:941-281-0991
Mailing Address - Fax:
Practice Address - Street 1:1111 DRURY LN
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-4545
Practice Address - Country:US
Practice Address - Phone:941-474-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant