Healthcare Provider Details

I. General information

NPI: 1326925298
Provider Name (Legal Business Name): IAN SIEGBERT STONE CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

9760 NW 18TH DR
PLANTATION FL
33322-5685
US

V. Phone/Fax

Practice location:
  • Phone: 954-939-5000
  • Fax:
Mailing address:
  • Phone: 407-558-0099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA1094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: