Provider Demographics
NPI:1104524107
Name:MACIAS, PAOLA GABRIELA (PA)
Entity type:Individual
Prefix:
First Name:PAOLA
Middle Name:GABRIELA
Last Name:MACIAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10987 SHELDON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4702
Mailing Address - Country:US
Mailing Address - Phone:813-467-4800
Mailing Address - Fax:
Practice Address - Street 1:10987 SHELDON RD STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4702
Practice Address - Country:US
Practice Address - Phone:813-467-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant