Provider Demographics
NPI:1851059547
Name:MIRADICI, ISABELA
Entity Type:Individual
Prefix:
First Name:ISABELA
Middle Name:
Last Name:MIRADICI
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 1:300 HEALTH PARK BLVD STE 4000
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3704
Mailing Address - Country:US
Mailing Address - Phone:904-824-8666
Mailing Address - Fax:904-486-2314
Practice Address - Street 1:300 HEALTH PARK BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3704
Practice Address - Country:US
Practice Address - Phone:904-824-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty