Provider Demographics
NPI:1457724403
Name:TANT, MAVANY (PA)
Entity Type:Individual
Prefix:
First Name:MAVANY
Middle Name:
Last Name:TANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAVANY
Other - Middle Name:
Other - Last Name:CAFFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 E PAR ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4003
Mailing Address - Country:US
Mailing Address - Phone:877-876-3627
Mailing Address - Fax:321-843-4101
Practice Address - Street 1:32 W GORE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1134
Practice Address - Country:US
Practice Address - Phone:877-876-3627
Practice Address - Fax:321-843-4101
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53260363A00000X
FLPA9109290363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021348500Medicaid
CAPA53260OtherCA PA LICENSE