Provider Demographics
NPI:1942728548
Name:VARIVODA, MARINA (PA)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:VARIVODA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SW 6TH AVE APT 603
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-4784
Mailing Address - Country:US
Mailing Address - Phone:786-298-4335
Mailing Address - Fax:
Practice Address - Street 1:50 SW 6TH AVE APT 603
Practice Address - Street 2:
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034-4784
Practice Address - Country:US
Practice Address - Phone:786-298-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-02
Last Update Date:2017-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant