1558470120 NPI number — MADONNA MIFSUD PACHOTA ARNP

Table of content: MADONNA MIFSUD PACHOTA ARNP (NPI 1558470120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558470120 NPI number — MADONNA MIFSUD PACHOTA ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIFSUD PACHOTA
Provider First Name:
MADONNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558470120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
STE. 301
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 TAMIAMI TRL S
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-357-4390
Provider Business Practice Location Address Fax Number:
941-357-4391
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  ARNP1810262 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 48336 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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