=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760208656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TESSA GARST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 02/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 671 S KINGS AVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-6048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-972-3750
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2109 STANTON HALL CT
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-6550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-600-8231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 9119821
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------