Provider Demographics
NPI:1366813966
Name:MARICHAL, MABEL (PA)
Entity type:Individual
Prefix:
First Name:MABEL
Middle Name:
Last Name:MARICHAL
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 1:12750 SW 128TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5380
Mailing Address - Country:US
Mailing Address - Phone:786-409-9490
Mailing Address - Fax:786-592-2008
Practice Address - Street 1:12750 SW 128TH ST STE 108
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5380
Practice Address - Country:US
Practice Address - Phone:786-409-9490
Practice Address - Fax:786-592-2008
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109072363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9109072OtherPHYSICIAN ASSISTANT