Healthcare Provider Details

I. General information

NPI: 1487112181
Provider Name (Legal Business Name): JOSE A IDONE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21378 MARINA COVE CIR APT B19
AVENTURA FL
33180-3562
US

IV. Provider business mailing address

21378 MARINA COVE CIR APT B19
AVENTURA FL
33180-3562
US

V. Phone/Fax

Practice location:
  • Phone: 305-570-7575
  • Fax:
Mailing address:
  • Phone: 305-570-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9111973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: