Provider Demographics
NPI:1184282907
Name:DAICOFF, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DAICOFF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 7TH ST S STE 205
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4748
Mailing Address - Country:US
Mailing Address - Phone:727-893-6235
Mailing Address - Fax:727-553-7422
Practice Address - Street 1:601 7TH ST S STE 205
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4748
Practice Address - Country:US
Practice Address - Phone:727-893-6235
Practice Address - Fax:727-553-7422
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9112118363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125349000Medicaid