Provider Demographics
NPI:1528456548
Name:FLORIDA PRACTITIONERS, LLC
Entity type:Organization
Organization Name:FLORIDA PRACTITIONERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TOBIAS
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:954-791-6146
Mailing Address - Street 1:PO BOX 936535
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6535
Mailing Address - Country:US
Mailing Address - Phone:954-791-6146
Mailing Address - Fax:954-337-2733
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1149
Practice Address - Country:US
Practice Address - Phone:615-657-4805
Practice Address - Fax:954-337-2733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3649363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020654300Medicaid