Provider Demographics
NPI:1194198770
Name:ILICH, MARICA (PA-C, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MARICA
Middle Name:
Last Name:ILICH
Suffix:
Gender:F
Credentials:PA-C, ATC, LAT
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 100905
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0905
Mailing Address - Country:US
Mailing Address - Phone:786-595-1310
Mailing Address - Fax:
Practice Address - Street 1:19955 NW 27TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-2675
Practice Address - Country:US
Practice Address - Phone:786-268-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117586363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant