Healthcare Provider Details

I. General information

NPI: 1659287621
Provider Name (Legal Business Name): TIAGO SAMPAIO DE OLIVEIRA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N MIAMI AVE APT 404
MIAMI FL
33127-4468
US

IV. Provider business mailing address

2700 N MIAMI AVE APT 404
MIAMI FL
33127-4468
US

V. Phone/Fax

Practice location:
  • Phone: 978-457-3403
  • Fax:
Mailing address:
  • Phone: 978-457-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3241
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: