Provider Demographics
NPI:1972157824
Name:BALTODANO, NASTASSIA G
Entity Type:Individual
Prefix:MRS
First Name:NASTASSIA
Middle Name:G
Last Name:BALTODANO
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 1:2802 SW 67TH LN
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4808
Mailing Address - Country:US
Mailing Address - Phone:954-643-5679
Mailing Address - Fax:
Practice Address - Street 1:9330 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1808
Practice Address - Country:US
Practice Address - Phone:727-834-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
FLAA517367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant