Healthcare Provider Details

I. General information

NPI: 1215313671
Provider Name (Legal Business Name): EMILY MATTEI GODFREY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

501 6TH AVE S STE 702A
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4343
  • Fax:
Mailing address:
  • Phone: 727-767-4343
  • Fax: 727-767-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9111269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: