Provider Demographics
NPI:1578672515
Name:TITOVA, JENYA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENYA
Middle Name:
Last Name:TITOVA
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 1:880 NW 13TH ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1870
Mailing Address - Country:US
Mailing Address - Phone:561-750-0544
Mailing Address - Fax:
Practice Address - Street 1:880 NW 13TH ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2342
Practice Address - Country:US
Practice Address - Phone:561-750-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00151100363A00000X
FLPA9106540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097443Medicare ID - Type Unspecified
NJQ61354Medicare UPIN