Provider Demographics
NPI:1558866095
Name:ITALIEN, MEDJINE GUYBERTE (PA-C)
Entity Type:Individual
Prefix:
First Name:MEDJINE
Middle Name:GUYBERTE
Last Name:ITALIEN
Suffix:
Gender:F
Credentials:PA-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 12493
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33101-2493
Mailing Address - Country:US
Mailing Address - Phone:305-585-5315
Mailing Address - Fax:305-355-2242
Practice Address - Street 1:100 NW 170TH ST STE 410
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5511
Practice Address - Country:US
Practice Address - Phone:305-654-6850
Practice Address - Fax:305-654-6858
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9111139Medicaid