Provider Demographics
NPI:1265428288
Name:FORTINGTON, MARIA L (PAC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:FORTINGTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5070 MINTON RD NW
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1157
Mailing Address - Country:US
Mailing Address - Phone:321-768-1600
Mailing Address - Fax:321-799-4903
Practice Address - Street 1:5070 MINTON RD NW
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1157
Practice Address - Country:US
Practice Address - Phone:321-768-1600
Practice Address - Fax:321-799-4903
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4289ZMedicare ID - Type Unspecified