Provider Demographics
NPI:1013938778
Name:WAIDELE, MIRNA ANTONIETA (PA)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:ANTONIETA
Last Name:WAIDELE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 W CAMINO REAL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-5510
Mailing Address - Country:US
Mailing Address - Phone:561-391-6552
Mailing Address - Fax:561-391-6285
Practice Address - Street 1:7100 W CAMINO REAL
Practice Address - Street 2:SUITE 200
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5510
Practice Address - Country:US
Practice Address - Phone:561-391-6552
Practice Address - Fax:561-391-6285
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101003363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical