Healthcare Provider Details

I. General information

NPI: 1093706079
Provider Name (Legal Business Name): MARGARET L AVILLA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S. HARBOR CITY BLVD SUITE 420
MELBOURNE FL
32901
US

IV. Provider business mailing address

2222 S. HARBOR CITY BLVD SUITE 420
MELBOURNE FL
32901
US

V. Phone/Fax

Practice location:
  • Phone: 321-768-9914
  • Fax: 321-953-1893
Mailing address:
  • Phone: 321-768-9914
  • Fax: 321-953-1893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2518
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2518
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: