Provider Demographics
NPI:1134372261
Name:O'MALLEY, JULIA (PA)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:O'MALLEY
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 1:1517 KESTREL WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8336
Mailing Address - Country:US
Mailing Address - Phone:954-695-5757
Mailing Address - Fax:
Practice Address - Street 1:214 MORRISON RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4849
Practice Address - Country:US
Practice Address - Phone:813-681-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9104739363A00000X
TXPA06250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX800N42OtherBLUE CROSS BLUE SHIELD
TX8L13855Medicare PIN