Provider Demographics
NPI:1750717377
Name:FERENTINO, MICHAEL JAMES (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:FERENTINO
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 1:13020 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0915
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6186
Practice Address - Street 1:909 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1251
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107469363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019828800Medicaid
FLY0L7KOtherFLORIDA BLUE
FLY0L7KOtherFLORIDA BLUE