Provider Demographics
NPI: | 1932522141 |
---|---|
Name: | LADD, MURIEL CHRISTINE (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | MURIEL |
Middle Name: | CHRISTINE |
Last Name: | LADD |
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: | 3126 W HAWTHORNE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | TAMPA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33611-2901 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-514-2130 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 501 6TH AVE S |
Practice Address - Street 2: | DEPT 6500000408 |
Practice Address - City: | ST PETERSBURG |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33701-4634 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-767-8480 |
Practice Address - Fax: | 727-767-8420 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-01-23 |
Last Update Date: | 2016-07-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PAT 9107774 | 363A00000X |
FL | PA9107774 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 012016900 | Medicaid |