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NPI Code Detail

MEDICARE: MISS MONICA TIRTARAHARDJA PA-C

MEDICARE: MISS MONICA TIRTARAHARDJA 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
1363AS0400XSurgical Physician AssistantPA9112886FL

General Provider Information

NPI Number : 1770117830
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS MONICA TIRTARAHARDJA PA-C
Provider Business Mailing Address
First Line : 5503 S CONGRESS AVE STE 204
Second Line :
City : ATLANTIS
State : FL
Zip : 33462-6626
Country : US
Telephone Number : 561-410-5110
Fax Number : 561-328-3911
Provider Business Practice Location Address
First Line : 5503 S CONGRESS AVE STE 204
Second Line :
City : LAKE WORTH
State : FL
Zip : 33462-6626
Country : US
Telephone Number : 561-410-5110
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2020
Last Update Date : 07/12/2020

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