Provider Demographics
NPI:1902576150
Name:IBRAHIM, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W COPELAND DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:321-841-7090
Mailing Address - Fax:321-843-2267
Practice Address - Street 1:125 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2101
Practice Address - Country:US
Practice Address - Phone:321-841-7090
Practice Address - Fax:321-843-2267
Is Sole Proprietor?:No
Enumeration Date:2021-09-19
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA9089363A00000X
FLPA9119022363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124041500Medicaid