Provider Demographics
NPI:1215103437
Name:TALLAHASSEE NEUROLOGICAL CLINIC PA
Entity type:Organization
Organization Name:TALLAHASSEE NEUROLOGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA C
Authorized Official - Phone:850-878-8121
Mailing Address - Street 1:1401 CENTERVILLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4647
Mailing Address - Country:US
Mailing Address - Phone:850-878-8121
Mailing Address - Fax:850-942-6515
Practice Address - Street 1:1401 CENTERVILLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4647
Practice Address - Country:US
Practice Address - Phone:850-878-8121
Practice Address - Fax:850-942-6515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty