Provider Demographics
NPI:1396264982
Name:ROBERTS, MICHAEL JESSIE VISITA (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL JESSIE
Middle Name:VISITA
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SCARLET BUGLER LN S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1648 ST. VINCENTS WAY
Practice Address - Street 2:100B
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068
Practice Address - Country:US
Practice Address - Phone:904-214-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27840225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant