Provider Demographics
NPI: | 1619952934 |
---|---|
Name: | MISECHOK, JENNIFER L (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | L |
Last Name: | MISECHOK |
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 40658 |
Mailing Address - Street 2: | |
Mailing Address - City: | ST PETERSBURG |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33743-0658 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-381-2500 |
Mailing Address - Fax: | 727-343-8746 |
Practice Address - Street 1: | 10 PASADENA AVE N |
Practice Address - Street 2: | |
Practice Address - City: | ST PETERSBURG |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33710-8330 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-381-2500 |
Practice Address - Fax: | 727-343-8746 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-09 |
Last Update Date: | 2022-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PA9103594 | 2083P0011X, 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No | 2083P0011X | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | PA9103594 | Other | LICENSE |