Provider Demographics
NPI:1033478755
Name:ADVANCED WOMEN'S UROLOGY AND GYNECOLOGY, PLLC
Entity Type:Organization
Organization Name:ADVANCED WOMEN'S UROLOGY AND GYNECOLOGY, PLLC
Other - Org Name:ADVANCED UROGYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-898-9804
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-898-9804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED WOMEN'S UROLOGY AND GYNECOLOGY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site