Basic Information
| Provider Information | |||||||||
| NPI: | 1689972192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | MICAH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 S ORLANDO AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327894870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078944693 | ||||||||
| FaxNumber: | 4072613869 | ||||||||
| Practice Location | |||||||||
| Address1: | 4100 METRIC DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327926837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076818720 | ||||||||
| FaxNumber: | 4076818729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9169904 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.