Provider Demographics
NPI:1083484562
Name:BASTERRECHEA, ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BASTERRECHEA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE STE 681
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4654
Mailing Address - Country:US
Mailing Address - Phone:407-821-3588
Mailing Address - Fax:
Practice Address - Street 1:2501 N ORANGE AVE STE 681
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4654
Practice Address - Country:US
Practice Address - Phone:407-821-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant