Healthcare Provider Details

I. General information

NPI: 1053711341
Provider Name (Legal Business Name): ADALYNE PERICLES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 SW 162ND AVE
MIAMI FL
33196-6408
US

IV. Provider business mailing address

PO BOX 198054
ATLANTA GA
30384-8054
US

V. Phone/Fax

Practice location:
  • Phone: 786-467-2154
  • Fax: 786-533-9703
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: