Healthcare Provider Details

I. General information

NPI: 1457724403
Provider Name (Legal Business Name): MAVANY TANT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAVANY CAFFREY

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 W GORE ST
ORLANDO FL
32806-1134
US

IV. Provider business mailing address

303 E PAR ST
ORLANDO FL
32804-4003
US

V. Phone/Fax

Practice location:
  • Phone: 877-876-3627
  • Fax: 321-843-4101
Mailing address:
  • Phone: 877-876-3627
  • Fax: 321-843-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA53260
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9109290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: