Provider Demographics
NPI:1831671742
Name:AMIMO, RICKY ANANGWE (PA-C)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:ANANGWE
Last Name:AMIMO
Suffix:
Gender:M
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 1:2415 N ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5505
Mailing Address - Country:US
Mailing Address - Phone:407-303-7250
Mailing Address - Fax:
Practice Address - Street 1:2415 N ORANGE AVE STE 302
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5505
Practice Address - Country:US
Practice Address - Phone:407-303-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1147739OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS ID
FLPA9111430OtherSTATE LICENCE