Provider Demographics
NPI:1891959490
Name:SHERIDAN, ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SHERIDAN
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 1:1010 PERRY AVE
Mailing Address - Street 2:#304
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-4801
Mailing Address - Country:US
Mailing Address - Phone:360-204-0712
Mailing Address - Fax:
Practice Address - Street 1:1010 PERRY AVE
Practice Address - Street 2:#304
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4801
Practice Address - Country:US
Practice Address - Phone:360-204-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-12
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60030974225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant