Provider Demographics
NPI:1427579432
Name:ANSARI, MUJIBA SANJAREEN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MUJIBA
Middle Name:SANJAREEN
Last Name:ANSARI
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3248 W PEBBLE BEACH CT
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-7774
Mailing Address - Country:US
Mailing Address - Phone:352-270-1527
Mailing Address - Fax:
Practice Address - Street 1:3248 W PEBBLE BEACH CT
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-7774
Practice Address - Country:US
Practice Address - Phone:352-270-1527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110443363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical