Basic Information
| Provider Information | |||||||||
| NPI: | 1205858719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARDETTE | ||||||||
| FirstName: | PETRINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HINRICHSEN | ||||||||
| OtherFirstName: | PETRINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3000 BAYVIEW DR | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333061772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545671332 | ||||||||
| FaxNumber: | 9545377705 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 BAYVIEW DR | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333061772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545671332 | ||||||||
| FaxNumber: | 9545377705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | ME0044395 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA3368 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 290935900 | 05 | FL | MEDICAID |