Healthcare Provider Details

I. General information

NPI: 1215851316
Provider Name (Legal Business Name): ELEVATE PCW FL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S ORANGE AVE STE 104
ORLANDO FL
32801-3411
US

IV. Provider business mailing address

20120 NATURES HIKE WAY
TAMPA FL
33647-3581
US

V. Phone/Fax

Practice location:
  • Phone: 469-693-7164
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AQSA JAMAL
Title or Position: OWNER
Credential:
Phone: 469-693-7164