Basic Information
| Provider Information | |||||||||
| NPI: | 1114455458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | LONG HOANG | ||||||||
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| Credential: | DPT PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4539 S DALE MABRY HWY | ||||||||
| Address2: | STE 110 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336111404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048293411 | ||||||||
| FaxNumber: | 9048293412 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048293411 | ||||||||
| FaxNumber: | 9048293412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT32562 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.