Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | ME 91464 | FL |
NPI | 1013938810 |
---|---|
Provider Name | Patricia Bravo |
First Address | North Bay Village, FL 33141-4188 |
Second Address | North Bay Village, FL 33141-4188 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 31/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
267682600 | (05) | FL |
H79303 | (02) |