Healthcare Provider Details

I. General information

NPI: 1144814815
Provider Name (Legal Business Name): COLE POMYKACZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 SE OCEAN BLVD
STUART FL
34994-2573
US

IV. Provider business mailing address

5854 SE HORSESHOE POINT RD
STUART FL
34997-2416
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-5955
  • Fax:
Mailing address:
  • Phone: 443-480-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114086
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: