Basic Information
| Provider Information | |||||||||
| NPI: | 1467605600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 220 S COURTENAY PKWY STE B | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 19601 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 24340 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | M9051 | 01 | FL | FL MEDICARE | OTHER |