Provider Demographics
NPI:1043689763
Name:ROMANOV, MINDY LEY (PA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LEY
Last Name:ROMANOV
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:LEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-917-7293
Mailing Address - Fax:
Practice Address - Street 1:6450 38TH AVE N STE 420
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1653
Practice Address - Country:US
Practice Address - Phone:727-344-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108984363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant