Basic Information
| Provider Information | |||||||||
| NPI: | 1427424811 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4319 E 7TH AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336054628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274392677 | ||||||||
| FaxNumber: | 7274997548 | ||||||||
| Practice Location | |||||||||
| Address1: | 4319 E 7TH AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336054628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274392677 | ||||||||
| FaxNumber: | 7274997548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | BONA | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 7274392677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.