Provider Demographics
NPI:1295047801
Name:ENTEZARI, MONA (PA-C)
Entity type:Individual
Prefix:MS
First Name:MONA
Middle Name:
Last Name:ENTEZARI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SW 101ST TERRACE
Mailing Address - Street 2:UNIT #411
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025
Mailing Address - Country:US
Mailing Address - Phone:954-319-6184
Mailing Address - Fax:
Practice Address - Street 1:4800 N. FEDERAL HWY
Practice Address - Street 2:SUITE C100
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431
Practice Address - Country:US
Practice Address - Phone:800-407-4319
Practice Address - Fax:561-886-0981
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant