Provider Demographics
NPI:1144808536
Name:DUBBANEH, JONATHAN (PTA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DUBBANEH
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 1:4405 BANYAN TREE PL
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3039
Mailing Address - Country:US
Mailing Address - Phone:941-268-5809
Mailing Address - Fax:
Practice Address - Street 1:2888 RINGLING BLVD UNIT CD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-5331
Practice Address - Country:US
Practice Address - Phone:941-413-5100
Practice Address - Fax:941-388-7292
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25514225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant