Provider Demographics
NPI:1669241295
Name:MEDVASIVE, LLC
Entity type:Organization
Organization Name:MEDVASIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:SA-C
Authorized Official - Phone:407-480-0295
Mailing Address - Street 1:16756 ABBEY HILL CT
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6353
Mailing Address - Country:US
Mailing Address - Phone:407-480-0295
Mailing Address - Fax:
Practice Address - Street 1:16756 ABBEY HILL CT
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6353
Practice Address - Country:US
Practice Address - Phone:407-480-0295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty