Provider Demographics
NPI:1467181115
Name:FORD, ANNIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:FORD
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 1:4421 POWDERHORN PLACE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8926
Mailing Address - Country:US
Mailing Address - Phone:407-705-7587
Mailing Address - Fax:
Practice Address - Street 1:4421 POWDERHORN PLACE DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8926
Practice Address - Country:US
Practice Address - Phone:407-705-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
9115846OtherPHYSICIAN ASSISTANT LICENSE NUMBER