Healthcare Provider Details

I. General information

NPI: 1336892892
Provider Name (Legal Business Name): NICHOLAS ANDREW MUDRA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

621 SW 77TH TER
GAINESVILLE FL
32607-1566
US

V. Phone/Fax

Practice location:
  • Phone: 800-324-8387
  • Fax:
Mailing address:
  • Phone: 352-316-4127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9115550
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: