=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528545647
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANNA SALAZAR PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2018
-----------------------------------------------------
Last Update Date | 04/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 SW 84TH AVE
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33324-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-665-4827
-----------------------------------------------------
Fax | 877-902-3831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 SW 84TH AVE
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33324-2731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-665-4827
-----------------------------------------------------
Fax | 877-902-3831
-----------------------------------------------------
=====================================================
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 | 022320
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9112797
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------