Basic Information
| Provider Information | |||||||||
| NPI: | 1285183236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACOSSE | ||||||||
| FirstName: | RUDY | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1444 NW 14TH AVE | ||||||||
| Address2: | APT 1507 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331251686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3057853858 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4801 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333283839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544341705 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2016 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9109705 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA060244 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.