Provider Demographics
NPI:1114669140
Name:BEREZDIVIN, RAQUEL ITA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:ITA
Last Name:BEREZDIVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:ITA
Other - Last Name:FRANCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:54 CALLE CALISTEMON
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-3166
Mailing Address - Country:US
Mailing Address - Phone:786-223-7624
Mailing Address - Fax:
Practice Address - Street 1:1511 AVENIDA DE LA CONSTITUCION
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-339-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113995363A00000X
PR845PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant