Provider Demographics
NPI:1669126405
Name:MIJATOVIC, MIROSLAV (PA)
Entity type:Individual
Prefix:
First Name:MIROSLAV
Middle Name:
Last Name:MIJATOVIC
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10475 GANDY BLVD N UNIT 2213
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2495
Mailing Address - Country:US
Mailing Address - Phone:727-557-6563
Mailing Address - Fax:
Practice Address - Street 1:5767 49TH ST N STE A
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2106
Practice Address - Country:US
Practice Address - Phone:727-350-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant