Provider Demographics
NPI:1265158695
Name:AZIZ, MENA
Entity type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:AZIZ
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 1:1501 RIVER REACH DR APT 275
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5840
Mailing Address - Country:US
Mailing Address - Phone:386-299-0574
Mailing Address - Fax:
Practice Address - Street 1:2948 W LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3416
Practice Address - Country:US
Practice Address - Phone:407-732-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant