MEDICARE: 1 STOP MEDICAL SHOP LLC

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	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1457015711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 STOP MEDICAL SHOP LLC

Provider Business Mailing Address
First Line	:	5036 TROUBLE CREEK RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-4904
Country	:	US
Telephone Number	:	727-816-9736
Fax Number	:	217-216-5092

Provider Business Practice Location Address
First Line	:	5036 TROUBLE CREEK RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-4904
Country	:	US
Telephone Number	:	727-816-9736
Fax Number	:	217-216-5092

Authorized Official
Title or Position	:	OWNER
Name	:	MS. DEBORA LYNN RYDER
Credential	:	APRN
Telephone Number	:	727-816-9736

Provider Enumeration Date	:	10/23/2021
Last Update Date	:	10/23/2021

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