Provider Demographics
NPI:1083786289
Name:PEARSON, MYRTLE M (NP)
Entity Type:Individual
Prefix:
First Name:MYRTLE
Middle Name:M
Last Name:PEARSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MYRTLE
Other - Middle Name:M
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:1605 PEACHTREE ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2433
Practice Address - Country:US
Practice Address - Phone:404-870-7746
Practice Address - Fax:404-870-7719
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN071972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26143Medicare UPIN
50BBHVGMedicare ID - Type Unspecified