Basic Information
| Provider Information | |||||||||
| NPI: | 1104265404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUCCIGROSSO | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 LOOKOUT PL | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215945523 | ||||||||
| FaxNumber: | 4073332140 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 LOOKOUT PL | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327514485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215945523 | ||||||||
| FaxNumber: | 4073332140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9107460 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.