Provider Demographics
NPI:1871286906
Name:SWANSON, BRADLEY (PTA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:SWANSON
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 1:10550 DEERWOOD PARK BLVD STE 609A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-2811
Mailing Address - Country:US
Mailing Address - Phone:904-513-3954
Mailing Address - Fax:
Practice Address - Street 1:10550 DEERWOOD PARK BLVD STE 609A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-2811
Practice Address - Country:US
Practice Address - Phone:904-513-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28191225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant