Healthcare Provider Details

I. General information

NPI: 1275009482
Provider Name (Legal Business Name): STEPHANIE NICOLAU RADUCU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 SW 57TH AVE STE 110
SOUTH MIAMI FL
33143-5543
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 305-740-6181
  • Fax: 305-741-6140
Mailing address:
  • Phone: 585-424-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9113455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: