Provider Demographics
NPI:1831112416
Name:NICODEMO, ROBERTO A (PA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:NICODEMO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:1044 PLAZA DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-4064
Practice Address - Country:US
Practice Address - Phone:407-350-5659
Practice Address - Fax:407-350-5662
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-02-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9101023OtherLICENSE NUMBER
FLPA9101023OtherLICENSE NUMBER
FLP09683Medicare UPIN