Healthcare Provider Details

I. General information

NPI: 1902576150
Provider Name (Legal Business Name): ROSE IBRAHIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2021
Last Update Date: 10/16/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W COPELAND DR
ORLANDO FL
32806-2101
US

IV. Provider business mailing address

125 W COPELAND DR
ORLANDO FL
32806
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7090
  • Fax: 321-843-2267
Mailing address:
  • Phone: 321-841-7090
  • Fax: 321-843-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9089
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9119022
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: