Healthcare Provider Details

I. General information

NPI: 1306611264
Provider Name (Legal Business Name): ANNA TERESA MIXA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 PASADENA AVE S STE 1A
SOUTH PASADENA FL
33707-4514
US

IV. Provider business mailing address

3612 EL CENTRO ST
ST PETE BEACH FL
33706-3908
US

V. Phone/Fax

Practice location:
  • Phone: 727-321-9644
  • Fax:
Mailing address:
  • Phone: 727-743-0728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118132
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: