Provider Demographics
NPI:1851059547
Name:MIRADICI, ISABELA (PA)
Entity type:Individual
Prefix:
First Name:ISABELA
Middle Name:
Last Name:MIRADICI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ISABELA
Other - Middle Name:
Other - Last Name:DOMINICI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 501
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5170
Mailing Address - Country:US
Mailing Address - Phone:386-615-0900
Mailing Address - Fax:386-615-0902
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 501
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5170
Practice Address - Country:US
Practice Address - Phone:386-615-0900
Practice Address - Fax:386-615-0902
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9116027OtherPA LICENSE