MEDICARE: MISS NICOLE ELYSE GENTILE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9105794	FL

General Provider Information

NPI Number	:	1073816005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NICOLE ELYSE GENTILE PA-C

Provider Business Mailing Address
First Line	:	151 SOUTHHALL LN STE 300
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7172
Country	:	US
Telephone Number	:	407-875-2080
Fax Number	:	407-650-3455

Provider Business Practice Location Address
First Line	:	4331 N FEDERAL HWY STE 400
Second Line	:
City	:	OAKLAND PARK
State	:	FL
Zip	:	33308-5252
Country	:	US
Telephone Number	:	954-772-0416
Fax Number	:	954-772-5716

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	07/21/2022

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