Provider Demographics
NPI:1588078000
Name:AL-JARBOUA, LA TASHA (PA-C)
Entity type:Individual
Prefix:
First Name:LA TASHA
Middle Name:
Last Name:AL-JARBOUA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 4TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2462
Mailing Address - Country:US
Mailing Address - Phone:833-399-0957
Mailing Address - Fax:727-335-1174
Practice Address - Street 1:9800 4TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2462
Practice Address - Country:US
Practice Address - Phone:833-399-0957
Practice Address - Fax:727-335-1174
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-048542084P0802X, 2084P0804X, 363A00000X
CA542342084P0802X, 363A00000X, 2084P0804X
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant