MEDICARE: JADE LUCIANA CARBONELLI 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

General Provider Information

NPI Number	:	1619674660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE LUCIANA CARBONELLI PA-C

Provider Business Mailing Address
First Line	:	18228 N US HIGHWAY 41
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33549-4400
Country	:	US
Telephone Number	:	813-321-1786
Fax Number	:	813-321-1787

Provider Business Practice Location Address
First Line	:	9170 OAKHURST RD STE 1
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33776-2112
Country	:	US
Telephone Number	:	813-321-1786
Fax Number	:	813-321-1787

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

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	08/26/2024

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