Individual
MR. IVAN BROADERICK GRESHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
45390 GREEN AVE, CALLAHAN, FL 32011-3711
(904) 879-1223
Mailing address
45390 GREEN AVE, CALLAHAN, FL 32011-3711
(904) 879-1223
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
PTA24242
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PTA24242
STATE LICENSE #
FL
Enumeration date
10/24/2013
Last updated
10/24/2013
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