Healthcare Provider Details

I. General information

NPI: 1487815163
Provider Name (Legal Business Name): ROSEMARIE NICHOLAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

IV. Provider business mailing address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2000
  • Fax: 813-910-4037
Mailing address:
  • Phone: 813-972-2000
  • Fax: 813-910-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA002411
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: