Provider Demographics
NPI:1982193363
Name:MASTROMARINO, NICHOLAS ANGELO
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANGELO
Last Name:MASTROMARINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 KRISWELL CT
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2648
Mailing Address - Country:US
Mailing Address - Phone:727-460-8949
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:MDC 30
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4749
Practice Address - Country:US
Practice Address - Phone:727-460-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI33142390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program