Healthcare Provider Details

I. General information

NPI: 1558866095
Provider Name (Legal Business Name): MEDJINE GUYBERTE ITALIEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NW 170TH ST STE 410
NORTH MIAMI BEACH FL
33169-5511
US

IV. Provider business mailing address

PO BOX 12493
MIAMI FL
33101-2493
US

V. Phone/Fax

Practice location:
  • Phone: 305-654-6850
  • Fax: 305-654-6858
Mailing address:
  • Phone: 305-585-5315
  • Fax: 305-355-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: