Healthcare Provider Details

I. General information

NPI: 1619504354
Provider Name (Legal Business Name): MYRTLE RIDGE PRIMARY CARE, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 DALE MABRY HWY STE 102
LUTZ FL
33548-3008
US

IV. Provider business mailing address

1539 DALE MABRY HWY STE 102
LUTZ FL
33548-3008
US

V. Phone/Fax

Practice location:
  • Phone: 813-909-7102
  • Fax: 813-909-0199
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: YUDAISY MOGENA PADRON
Title or Position: OWNER
Credential:
Phone: 813-909-7102