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General NPI Number Information
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NPI Number | 1124471503
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Entity Type | Organization
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Legal Business Name | ELLENTON FAMILY PRACTICE DIRECT PLLC
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Dates
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Enumeration Date | 07/20/2016
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 907 25TH DR E
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City | ELLENTON
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State | FL
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Zip | 34222-2053
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Country | US
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Telephone | 941-321-8299
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Fax |
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Provider Business Mailing Address
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Address Line | 907 25TH DR E
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City | ELLENTON
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State | FL
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Zip | 34222-2053
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Country | US
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Telephone | 941-417-7386
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGE AND PARTNER
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Name | MR. DAVID ALLAN HERVIG
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Credential | PA-C
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Telephone | 941-730-5326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | PA9102767
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License Number State | FL
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