Provider Demographics
NPI:1154307353
Name:VELOSA, DUARTE (PA)
Entity Type:Individual
Prefix:
First Name:DUARTE
Middle Name:
Last Name:VELOSA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:600 E DIXIE AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9103207363AM0700X
FLPA9103207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00296777OtherRR MCR
FL292237100Medicaid
P00296777OtherRR MCR
FL05164UMedicare PIN
FLU5164AMedicare PIN