Healthcare Provider Details

I. General information

NPI: 1073062121
Provider Name (Legal Business Name): JENNY MARIAN RODRIGUEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 W LUMSDEN RD
BRANDON FL
33511-5911
US

IV. Provider business mailing address

8102 TOM SAWYER DR
TAMPA FL
33637-6593
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-7726
  • Fax:
Mailing address:
  • Phone: 813-507-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: