Healthcare Provider Details

I. General information

NPI: 1063115475
Provider Name (Legal Business Name): SARAH HODGE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 N WICKHAM RD
MELBOURNE FL
32940-2006
US

IV. Provider business mailing address

6619 N WICKHAM RD
MELBOURNE FL
32940-2006
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-9500
  • Fax: 321-574-8656
Mailing address:
  • Phone: 321-259-9500
  • Fax: 321-574-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9117077
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: