Provider Demographics
NPI:1275158420
Name:MEDI-EAGLE EXPRESS HEALTHCARE LLC
Entity Type:Organization
Organization Name:MEDI-EAGLE EXPRESS HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICAELA
Authorized Official - Middle Name:N
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-927-2891
Mailing Address - Street 1:4202 BERRY COVE CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-7216
Mailing Address - Country:US
Mailing Address - Phone:407-927-2891
Mailing Address - Fax:
Practice Address - Street 1:4202 BERRY COVE CIR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-7216
Practice Address - Country:US
Practice Address - Phone:407-927-2891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-13
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP144351OtherPROVIDER LICENSE NUMBER