Healthcare Provider Details

I. General information

NPI: 1578592085
Provider Name (Legal Business Name): KIM A NORDELO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SE 17TH ST #100
OCALA FL
34471-3968
US

IV. Provider business mailing address

1015 SE 17TH ST #100
OCALA FL
34471-3968
US

V. Phone/Fax

Practice location:
  • Phone: 352-351-3422
  • Fax: 351-351-9129
Mailing address:
  • Phone: 352-351-3422
  • Fax: 351-351-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3498
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: