Provider Demographics
NPI:1093806515
Name:RANKIN, MARIO TEODORO (PAC)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:TEODORO
Last Name:RANKIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 135751
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34713-5751
Mailing Address - Country:US
Mailing Address - Phone:813-495-5823
Mailing Address - Fax:
Practice Address - Street 1:400 1ST STREET NORTH
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-299-2420
Practice Address - Fax:863-299-2460
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P353530001Medicare UPIN