Provider Demographics
NPI:1063526200
Name:GROSS, PATRICIA JEAN (PT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:GROSS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401-C PENMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3447
Mailing Address - Country:US
Mailing Address - Phone:904-242-0707
Mailing Address - Fax:904-242-0500
Practice Address - Street 1:1401-C PENMAN ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3447
Practice Address - Country:US
Practice Address - Phone:904-242-0707
Practice Address - Fax:904-242-0500
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0008057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8549Medicare PIN