MEDICARE: MISS ANGELA MICHELLE BALFOUR P.A.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	PA-9104872	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000382162	OTHER	OH	ANTHERM

General Provider Information

NPI Number	:	1487636320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ANGELA MICHELLE BALFOUR P.A.C.

Provider Business Mailing Address
First Line	:	2276 LAUREN LN
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-1437
Country	:	US
Telephone Number	:	513-716-7751
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 N ROCKY POINT DR E
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-5810
Country	:	US
Telephone Number	:	813-289-9613
Fax Number	:	484-253-1790

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	01/29/2015

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