Healthcare Provider Details

I. General information

NPI: 1457786691
Provider Name (Legal Business Name): MICHAEL PATRICK MCCRUDDEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 N ORANGE BLOSSOM TRL
ORLANDO FL
32804-4803
US

IV. Provider business mailing address

2314 N ORANGE BLOSSOM TRL
ORLANDO FL
32804-4803
US

V. Phone/Fax

Practice location:
  • Phone: 407-428-9233
  • Fax: 407-428-9667
Mailing address:
  • Phone: 407-428-9233
  • Fax: 407-428-9667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9107456
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: