Basic Information
| Provider Information | |||||||||
| NPI: | 1295368413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SY | ||||||||
| FirstName: | ALEXANDER | ||||||||
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| Credential: | PTA | ||||||||
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| OtherLastName: | SY | ||||||||
| OtherFirstName: | ALEX | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9564 WORTHINGTON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328298205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4077213558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1275 W GRANADA BLVD STE 4B2 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866151112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2020 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PTA29823 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.