Active NPI
Myrtle Ridge Primary Care, P.a
- General Practice Physician
- Lutz, FL
National Provider Identifier
1619504354
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Physician
- Legal business name
- MYRTLE RIDGE PRIMARY CARE, P.A
- Doing business as
- Myrtle Ridge Primary Care, P.A
- Practice address
- 1539 Dale Mabry Hwy Ste 102
Lutz, FL 33548-3008 - Phone
- (813) 909-7102
- Fax
- (813) 909-0199
- NPI assigned
- Mar 24, 2020
- Last updated
- Jan 8, 2026
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Yudaisy Mogena Padron
- Title
- Owner
- Phone
- (813) 909-7102
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | NU | ||
| Psychologist | 103T00000X | NU | ||
| General Practice Physician | 208D00000X | NU | Primary | |
| Physician Assistant | 363A00000X | NU |
Addresses
Primary practice location
1539 Dale Mabry Hwy Ste 102
Lutz, FL 33548-3008
Mailing address
1539 Dale Mabry Hwy Ste 102
Lutz, FL 33548-3008
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 129484600 | Medicaid | FL | |
| 10D1050075 | Other | FL | CLIA |
| 129485400 | Medicaid | FL |
Other names 1
- Myrtle Ridge Primary Care, P.A
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in FL
Enrollment records 1
National Provider Directory
National Provider Directory- Tax ID family
- Myrtle Ridge Primary Care
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Case Management Agency
- Lutz, FL
- NPI 1700553633
Locations
1539 Dale Mabry Hwy
Ste 102
Lutz, FL 33548
Phone (813) 909-7102
Networks
- Freedom Health HMO Network
- HealthSun Health Plans Network
- Optimum HealthCare HMO Network
Practitioners & affiliated clinicians
Practitioners 9
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.
-
- Psychologist
- Palm Springs, FL
- NPI 1821597014
-
- Psychiatric/Mental Health Nurse Practitioner
- Lutz, FL
- NPI 1548986987
-
- Marriage & Family Therapist
- Tampa, FL
- NPI 1982071056
-
- General Practice Physician
- Tampa, FL
- NPI 1144460684
-
- Clinical Psychologist
- Tampa, FL
- NPI 1063609683
-
- Physician Assistant
- Lutz, FL
- NPI 1831800218
-
- Psychiatric/Mental Health Nurse Practitioner
- Miami, FL
- NPI 1649127275
-
- Physician Assistant
- Lutz, FL
- NPI 1457178071
-
- Case Manager/Care Coordinator
- Lutz, FL
- NPI 1942018809
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1585008000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1767830400000",
"number": "1619504354",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1539 DALE MABRY HWY STE 102",
"city": "LUTZ",
"state": "FL",
"postal_code": "335483008"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1539 DALE MABRY HWY STE 102",
"city": "LUTZ",
"state": "FL",
"postal_code": "335483008",
"telephone_number": "813-909-7102",
"fax_number": "813-909-0199"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MYRTLE RIDGE PRIMARY CARE, P.A",
"organizational_subpart": "NO",
"enumeration_date": "2020-03-24",
"last_updated": "2026-01-08",
"certification_date": "2026-01-08",
"status": "A",
"authorized_official_last_name": "MOGENA PADRON",
"authorized_official_first_name": "YUDAISY",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "813-909-7102"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "NU",
"license": null,
"primary": false
},
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "NU",
"license": null,
"primary": false
},
{
"code": "208D00000X",
"taxonomy_group": "",
"desc": "General Practice",
"state": "NU",
"license": null,
"primary": true
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NU",
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "129484600",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CLIA",
"identifier": "10D1050075",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "129485400",
"state": "FL"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Myrtle Ridge Primary Care, P.A",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lutz, FL
- Terrence Cameron Myers Jr., PHARMD
- Myofascial Release and Women's Health LLC (Holistic Health Practitioners)
- Callie Myrick
- Myrtle Ridge Family Medicine, PA
- Myrtle Ridge Healthcare Center, LLC
- Myrtle Ridge Primary Care, P.a
- N Shape & Health Medicine LLC
- Marie Louise Nace
- Jordan Michael Nagle
- Sara Kietzman Nagy, M.S., CCC-SLP
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.