Healthcare Provider Details

I. General information

NPI: 1851799225
Provider Name (Legal Business Name): CARMEN MERCEDES LEDESMA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 BAXTER RIDGE CT
APEX NC
27502-4331
US

IV. Provider business mailing address

1409 BAXTER RIDGE CT
APEX NC
27502-4331
US

V. Phone/Fax

Practice location:
  • Phone: 305-331-6960
  • Fax:
Mailing address:
  • Phone: 305-331-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108123
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier102172100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: