Provider Demographics
NPI:1922401967
Name:BAO, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BAO
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 1:8025 SW 17TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1321
Mailing Address - Country:US
Mailing Address - Phone:305-877-1798
Mailing Address - Fax:
Practice Address - Street 1:8025 SW 17TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1321
Practice Address - Country:US
Practice Address - Phone:305-877-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant