Healthcare Provider Details

I. General information

NPI: 1275672842
Provider Name (Legal Business Name): MA.VICTORIA MALLARI YANGCO-GIBSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 SW 88TH ST SUITE 175
MIAMI FL
33186-1515
US

IV. Provider business mailing address

9260 NW 12TH AVE
MIAMI FL
33150-2022
US

V. Phone/Fax

Practice location:
  • Phone: 305-387-0051
  • Fax:
Mailing address:
  • Phone: 305-899-9494
  • Fax: 305-899-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9100987
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: