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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