Basic Information
Provider Information | |||||||||
NPI: | 1548930498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLADO | ||||||||
FirstName: | STEPHANIE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ORTIZ | ||||||||
OtherFirstName: | STEPHANIE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2080 OAKLEY SEAVER DR STE 120&130 | ||||||||
Address2: |   | ||||||||
City: | CLERMONT | ||||||||
State: | FL | ||||||||
PostalCode: | 347111962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3218416444 | ||||||||
FaxNumber: | 4076501307 | ||||||||
Practice Location | |||||||||
Address1: | 2080 OAKLEY SEAVER DR STE 120&130 | ||||||||
Address2: |   | ||||||||
City: | CLERMONT | ||||||||
State: | FL | ||||||||
PostalCode: | 347111962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3218416444 | ||||||||
FaxNumber: | 4076501307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2021 | ||||||||
LastUpdateDate: | 11/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9115127 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X |   | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.