MEDICARE: MISS NHI MA DO 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	363AM0700X	Medical Physician Assistant	PA9110668	FL

General Provider Information

NPI Number	:	1770094088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NHI MA DO PA-C

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 400
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-2051
Country	:	US
Telephone Number	:	305-500-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 S NOVA RD STE 4&5
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-0410
Country	:	US
Telephone Number	:	386-506-0111
Fax Number	:

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

Provider Enumeration Date	:	10/14/2017
Last Update Date	:	01/19/2024

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