=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831850551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSE MARY EWING PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2022
-----------------------------------------------------
Last Update Date | 01/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 S ANDREWS AVE
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33069-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-812-6204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2640 SW 12TH CT
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33442-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-812-6204
-----------------------------------------------------
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 | PA9102577
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | PA9102577
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9102577
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------