Healthcare Provider Details

I. General information

NPI: 1619799541
Provider Name (Legal Business Name): MIA GENERA FORTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

8096 HERITAGE DR
ALBURTIS PA
18011-2714
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-6510
  • Fax: 302-733-3340
Mailing address:
  • Phone: 610-554-6013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012201
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066138
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: