Provider Demographics
NPI:1477550176
Name:SMALL, JACOB (PHD, ARNP-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:PHD, ARNP-C
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 143410
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:372 W 47TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3950
Practice Address - Country:US
Practice Address - Phone:305-698-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-03-21
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
FLARNP2163832363L00000X
FLME51250208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304943400Medicaid
FLY0025Medicare ID - Type Unspecified
FLP34904Medicare UPIN