=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205566833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADAY CAMPO-HERNANDEZ PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2022
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1090 W STATE ROAD 436
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-869-1030
-----------------------------------------------------
Fax | 407-869-1025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 USTLER RD
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32712-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-766-5099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9116203
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------