Basic Information
| Provider Information | |||||||||
| NPI: | 1851860951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST FLORIDA GERIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5997 CHERRY HILL CIR | ||||||||
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| City: | PACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325719382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503848969 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5530 NORTHROP RD | ||||||||
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| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325708701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509838888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2018 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | HODSON | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 8503848969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 101613300 | 05 | FL | MEDICAID |