Provider Demographics
NPI:1770193500
Name:MY PHYSICIAN ONLINE
Entity type:Organization
Organization Name:MY PHYSICIAN ONLINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGGINS-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:954-778-8007
Mailing Address - Street 1:9540 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4974
Mailing Address - Country:US
Mailing Address - Phone:954-778-8007
Mailing Address - Fax:949-655-8591
Practice Address - Street 1:9540 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4974
Practice Address - Country:US
Practice Address - Phone:954-778-8007
Practice Address - Fax:949-655-8591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty