Basic Information
| Provider Information | |||||||||
| NPI: | 1609958883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEET | ||||||||
| FirstName: | JAROSLAVA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496907 | ||||||||
| FaxNumber: | 4074812035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328061215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076496907 | ||||||||
| FaxNumber: | 4074812035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 00000PA16743 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA9105962 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | PA9105962 | 01 | FL | MEDICAL LICENSE | OTHER | 004957100 | 05 | FL | MEDICAID |