Provider Demographics
NPI:1710578042
Name:PASSAGLIA, NIKOL VANESSA
Entity Type:Individual
Prefix:
First Name:NIKOL
Middle Name:VANESSA
Last Name:PASSAGLIA
Suffix:
Gender:F
Credentials:
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 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:
Practice Address - Street 1:19203 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-5067
Practice Address - Country:US
Practice Address - Phone:813-397-5300
Practice Address - Fax:813-726-0368
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9117469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPAT9117469OtherMEDICAL LICENSE