Healthcare Provider Details

I. General information

NPI: 1215326582
Provider Name (Legal Business Name): DRISS FIKRY PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 6TH ST S
ST PETERSBURG FL
33701-4814
US

IV. Provider business mailing address

6960 20TH AVE N APT 107B
ST PETERSBURG FL
33710-4798
US

V. Phone/Fax

Practice location:
  • Phone: 727-893-1234
  • Fax:
Mailing address:
  • Phone: 727-455-3478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9108440
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: