Healthcare Provider Details

I. General information

NPI: 1295379444
Provider Name (Legal Business Name): CELIA REZNITSKY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 NE 203RD ST STE 105
MIAMI FL
33180-1903
US

IV. Provider business mailing address

1101 NE 170TH ST
MIAMI FL
33162-2633
US

V. Phone/Fax

Practice location:
  • Phone: 305-692-8998
  • Fax:
Mailing address:
  • Phone: 305-989-9367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9112523
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: