Healthcare Provider Details

I. General information

NPI: 1760167233
Provider Name (Legal Business Name): BLUE WAVE MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 DREW ST
CLEARWATER FL
33765-2921
US

IV. Provider business mailing address

1105 S FORT HARRISON AVE
CLEARWATER FL
33756-3907
US

V. Phone/Fax

Practice location:
  • Phone: 917-576-7624
  • Fax:
Mailing address:
  • Phone: 727-303-3117
  • Fax: 727-335-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AUDREY Z PAUL
Title or Position: OWNER
Credential: MD
Phone: 917-576-7624