MEDICARE: SUSELY C RODRIGUEZ PA-C

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	363AM0700X	Medical Physician Assistant	9115448	FL
2	363AS0400X	Surgical Physician Assistant	9115448	FL
3	363A00000X	Physician Assistant	9115448	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	:	1750036455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSELY C RODRIGUEZ PA-C

Provider Business Mailing Address
First Line	:	7208 WANDO AVE
Second Line	:
City	:	GRANT
State	:	FL
Zip	:	32949-5350
Country	:	US
Telephone Number	:	321-986-9152
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 S HARBOR CITY BLVD
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32901-3242
Country	:	US
Telephone Number	:	321-725-8919
Fax Number	:

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

Provider Enumeration Date	:	02/21/2022
Last Update Date	:	02/21/2022

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