Healthcare Provider Details

I. General information

NPI: 1578868378
Provider Name (Legal Business Name): MAYLINE CORDOVA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BROAD ST FL 45
NEW YORK NY
10004-2942
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 954-967-6550
  • Fax: 954-967-8419
Mailing address:
  • Phone: 410-658-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9105854
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024981
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: