Provider Demographics
NPI:1124466685
Name:PENANO, EDGAR COMSON (PT)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:COMSON
Last Name:PENANO
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 1:7331 COLLEGE PKWY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5524
Mailing Address - Country:US
Mailing Address - Phone:239-334-5300
Mailing Address - Fax:
Practice Address - Street 1:7331 COLLEGE PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5524
Practice Address - Country:US
Practice Address - Phone:239-334-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT00007217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist