MEDICARE: ELISA D. ENDICOTT P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA3672	FL
2	207N00000X	Dermatology Physician	PA3672	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558314963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISA D. ENDICOTT P.A.

Provider Business Mailing Address
First Line	:	801 N ORANGE AVE
Second Line	:	SUITE 520
City	:	ORLANDO
State	:	FL
Zip	:	32801-1026
Country	:	US
Telephone Number	:	407-992-0660
Fax Number	:	407-992-7702

Provider Business Practice Location Address
First Line	:	801 N ORANGE AVE
Second Line	:	SUITE 520
City	:	ORLANDO
State	:	FL
Zip	:	32801-1026
Country	:	US
Telephone Number	:	407-992-0660
Fax Number	:	407-992-7702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	02/17/2011

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