Provider Demographics
NPI:1932596111
Name:COLOMBO, GREG P (PTA)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:P
Last Name:COLOMBO
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 1:4119 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5109
Mailing Address - Country:US
Mailing Address - Phone:941-408-8800
Mailing Address - Fax:941-408-0255
Practice Address - Street 1:4119 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5109
Practice Address - Country:US
Practice Address - Phone:941-408-8800
Practice Address - Fax:941-408-0255
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA14538225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA14538OtherSTATE LICENSE