Provider Demographics
NPI:1972238426
Name:MARTIN, DYLAN MICHAEL (PTA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:MICHAEL
Last Name:MARTIN
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 1:5522 FORESTER POND AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4825
Mailing Address - Country:US
Mailing Address - Phone:484-363-0704
Mailing Address - Fax:
Practice Address - Street 1:333 TAMIAMI TRL S STE 207
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2424
Practice Address - Country:US
Practice Address - Phone:941-484-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA32074225200000X
PATE011902225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant