1649465857 NPI number — JESSICA BASTOS OLIVEIRA MSPA, PA-C

Table of content: JESSICA BASTOS OLIVEIRA MSPA, PA-C (NPI 1649465857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649465857 NPI number — JESSICA BASTOS OLIVEIRA MSPA, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLIVEIRA
Provider First Name:
JESSICA
Provider Middle Name:
BASTOS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPA, PA-C
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:
1649465857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7421 SW 163RD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33193-4422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
917-495-1632
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11200 SW 8 STREET
Provider Second Line Business Practice Location Address:
GREEN LIBRARY, ROOM 475
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33199-3319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-495-1632
Provider Business Practice Location Address Fax Number:
917-495-1632
Provider Enumeration Date:
09/11/2007

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: 363A00000X , with the licence number:  0119001 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9109706 , 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)





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