=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013613082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA JING-YUEN SO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2023
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 DON WICKHAM DR STE 120
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-241-7050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10504 CORY LAKE DR
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33647-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------