Provider Demographics
NPI:1982600698
Name:SANDERS, NELSON WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:NELSON
Middle Name:WAYNE
Last Name:SANDERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2544 HIGHWAY 277
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:FL
Mailing Address - Zip Code:32462-3382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1827 HARRISON AVE
Practice Address - Street 2:UNIT 4
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7606
Practice Address - Country:US
Practice Address - Phone:850-872-7022
Practice Address - Fax:850-872-7021
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 21408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY051FZMedicare NSC