=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134370331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINA NESCOT PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2008
-----------------------------------------------------
Last Update Date | 07/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 HEALTHCARE WAY
-----------------------------------------------------
City | NORTH VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34275-3669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-366-9222
-----------------------------------------------------
Fax | 941-365-2269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 947407
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30394-7407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-917-2600
-----------------------------------------------------
Fax | 941-917-7884
-----------------------------------------------------
=====================================================
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 | 60672600
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9115768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------