Basic Information
| Provider Information | |||||||||
| NPI: | 1659996361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELAGE | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 NE 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326414615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208699718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522655911 | ||||||||
| FaxNumber: | 3522655606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA9113315 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.