Provider Demographics
NPI:1326769803
Name:FORD, MARIAH JADE
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:JADE
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4518
Mailing Address - Country:US
Mailing Address - Phone:813-882-9986
Mailing Address - Fax:813-882-9849
Practice Address - Street 1:1005 E BOYER ST
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-5501
Practice Address - Country:US
Practice Address - Phone:727-934-7638
Practice Address - Fax:727-944-4052
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116401363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant