MEDICARE: MS. REKHA NIDADAVOLU PHYSICIAN ASSISTANT

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	183500000X	Pharmacist	PS44664	FL
2	183500000X	Pharmacist	24667	MA
3	363A00000X	Physician Assistant	PA9111839	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	24667	OTHER	MA	PHARMACIST LICENSE
2	PS44664	OTHER	FL	FLORIDA BOARD OF PHARMACY
3	PA9111839	OTHER	FL	FLORIDA PHYSICIAN ASSISTANT BOARD

General Provider Information

NPI Number	:	1902138217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REKHA NIDADAVOLU PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	4745 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1400
Country	:	US
Telephone Number	:	305-905-9316
Fax Number	:

Provider Business Practice Location Address
First Line	:	4745 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1400
Country	:	US
Telephone Number	:	305-905-9316
Fax Number	:

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

Provider Enumeration Date	:	02/11/2010
Last Update Date	:	01/30/2020

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