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Organization
MYRTLE RIDGE PRIMARY CARE, P.A
Active
Organization
MYRTLE RIDGE PRIMARY CARE, P.A
Active
Other names
Myrtle Ridge Primary Care, P.A
Organization subpart
No
Provider details
NPI number
Authorized official
YUDAISY MOGENA PADRON (OWNER)
(813) 909-7102
Entity
Organization
Contact information
Practice address
1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008
(813) 909-7102
(813) 909-0199
Mailing address
1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103T00000X
Psychologist
—
—
208D00000X
General Practice Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10D1050075
CLIA
FL
05
—
129484600
—
FL
05
—
129485400
—
FL
Enumeration date
03/24/2020
Last updated
01/08/2026
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