Active NPI
Paul David Provenzano, DPT
- Physical Therapist
- Jacksonville, FL
National Provider Identifier
1275901878
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- PT30384
- Practice address
- 14546 Old Saint Augustine Rd
Jacksonville, FL 32258-5468 - Phone
- (904) 271-6575
- NPI assigned
- Sep 14, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | PT30384 | FL | Primary |
Addresses
Primary practice location
14546 Old Saint Augustine Rd
Jacksonville, FL 32258-5468
Mailing address
14546 Old Saint Augustine Rd
Jacksonville, FL 32258-5468
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT30384 | FL | MD | Physical Therapist |
Interoperability endpoints
- paul.provenzano.1@16002.direct.athenahealth.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1442188800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1442188800000",
"number": "1275901878",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14546 OLD SAINT AUGUSTINE RD",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322585468"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "14546 OLD SAINT AUGUSTINE RD",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322585468",
"telephone_number": "904-271-6575"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PROVENZANO",
"first_name": "PAUL",
"middle_name": "DAVID",
"name_prefix": "Dr.",
"credential": "DPT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-09-14",
"last_updated": "2015-09-14",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "FL",
"license": "PT30384",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jacksonville, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.