Healthcare Provider Details

I. General information

NPI: 1124849047
Provider Name (Legal Business Name): AMIRA ELTANTAWY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-2937
US

IV. Provider business mailing address

PO BOX 100225
GAINESVILLE FL
32610-0225
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8737
  • Fax: 352-273-9154
Mailing address:
  • Phone: 352-273-8737
  • Fax: 352-273-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9119245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: