Provider Demographics
NPI:1093224347
Name:CIVIL, EMMANUEL (SA-C)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:CIVIL
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23237 SW 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-2023
Mailing Address - Country:US
Mailing Address - Phone:561-891-3316
Mailing Address - Fax:
Practice Address - Street 1:23237 SW 61ST AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-2023
Practice Address - Country:US
Practice Address - Phone:561-891-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000263-P.A363A00000X
FL17-460246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant