Healthcare Provider Details

I. General information

NPI: 1538717806
Provider Name (Legal Business Name): MIA ROSE O'MARA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2868 S ALAFAYA TRL STE 130
ORLANDO FL
32828-7974
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7172
US

V. Phone/Fax

Practice location:
  • Phone: 407-770-0063
  • Fax: 407-770-0129
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: