# MYRTLE RIDGE PRIMARY CARE, P.A

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Myrtle Ridge Primary Care, P.A
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619504354
- **Authorized official:** YUDAISY MOGENA PADRON (OWNER)
- **Authorized official phone:** (813) 909-7102

## Contact information

- **Practice address:** 1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008
- **Practice address phone:** (813) 909-7102
- **Practice address fax:** (813) 909-0199
- **Mailing address:** 1539 DALE MABRY HWY STE 102, LUTZ, FL 33548-3008

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YM0800X | Mental Health Counselor | — | — | — |
| 103T00000X | Psychologist | — | — | — |
| 208D00000X | General Practice Physician | — | — | Yes |
| 363A00000X | Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 03/24/2020
- **Last updated:** 01/08/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 10D1050075 | CLIA | FL |
| 05 | — | 129484600 | — | FL |
| 05 | — | 129485400 | — | FL |