Provider Demographics
NPI:1144845413
Name:MICHOTA, STASE ELENA
Entity type:Individual
Prefix:
First Name:STASE
Middle Name:ELENA
Last Name:MICHOTA
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 1:1285 79TH ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2718
Mailing Address - Country:US
Mailing Address - Phone:727-492-8240
Mailing Address - Fax:
Practice Address - Street 1:6901 22ND AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3943
Practice Address - Country:US
Practice Address - Phone:727-341-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner