Healthcare Provider Details

I. General information

NPI: 1780679399
Provider Name (Legal Business Name): CAROL A KOIRO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 35TH LN SUITE 100
VERO BEACH FL
32960-6521
US

IV. Provider business mailing address

1155 35TH LN SUITE 100
VERO BEACH FL
32960-6521
US

V. Phone/Fax

Practice location:
  • Phone: 772-569-2330
  • Fax: 772-569-2630
Mailing address:
  • Phone: 772-569-2330
  • Fax: 772-569-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00077800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT00159OA
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105520
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: