Provider Demographics
NPI:1770117830
Name:TIRTARAHARDJA, MONICA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MONICA
Middle Name:
Last Name:TIRTARAHARDJA
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 1:5503 S CONGRESS AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6626
Mailing Address - Country:US
Mailing Address - Phone:561-410-5110
Mailing Address - Fax:561-328-3911
Practice Address - Street 1:5503 S CONGRESS AVE STE 204
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33462-6626
Practice Address - Country:US
Practice Address - Phone:561-410-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112886363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical