Healthcare Provider Details

I. General information

NPI: 1053376012
Provider Name (Legal Business Name): MICKEY L BATH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-8025
US

V. Phone/Fax

Practice location:
  • Phone: 352-392-1161
  • Fax: 352-392-5127
Mailing address:
  • Phone: 352-392-1161
  • Fax: 352-392-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 0002191
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: