Provider Demographics
NPI:1689972192
Name:FORMAN, MICAH J (ARNP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:J
Last Name:FORMAN
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
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Mailing Address - Street 1:807 S ORLANDO AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4870
Mailing Address - Country:US
Mailing Address - Phone:407-894-4693
Mailing Address - Fax:407-261-3869
Practice Address - Street 1:4100 METRIC DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-6837
Practice Address - Country:US
Practice Address - Phone:407-681-8720
Practice Address - Fax:407-681-8729
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9169904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner