Provider Demographics
NPI:1679808588
Name:CRUZ, MAYCIE A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MAYCIE
Middle Name:A
Last Name:CRUZ
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 1:260 NORTH TROPICAL TRAIL
Mailing Address - Street 2:STE 105
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4800
Mailing Address - Country:US
Mailing Address - Phone:321-208-8258
Mailing Address - Fax:321-735-7186
Practice Address - Street 1:260 NORTH TROPICAL TRAIL
Practice Address - Street 2:STE 105
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4800
Practice Address - Country:US
Practice Address - Phone:321-208-8258
Practice Address - Fax:321-735-7186
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159277AMedicaid
FL0015149-00Medicaid
FL013906100Medicaid
FL013906100Medicaid
FLCP561YMedicare PIN
GA003159277AMedicaid