=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457690265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY VICTORIA ENDRESON PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2013
-----------------------------------------------------
Last Update Date | 02/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8950 SW 74TH CT APT 1408
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156-3173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-274-7878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 511 SE 5TH AVE APT 1403
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-2973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-779-6792
-----------------------------------------------------
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 | PA9106917
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------