Provider Demographics
NPI:1154567063
Name:CALDERON, MIKEL (PA)
Entity type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:CALDERON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W BROWARD BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1417
Mailing Address - Country:US
Mailing Address - Phone:954-792-1010
Mailing Address - Fax:954-792-1199
Practice Address - Street 1:2307 W BROWARD BLVD
Practice Address - Street 2:STE 200
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1417
Practice Address - Country:US
Practice Address - Phone:954-792-1010
Practice Address - Fax:954-792-1199
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109411363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABO758WOtherPTAN