Provider Demographics
NPI:1154832632
Name:DURSO, SVETLANA (PA-C)
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:DURSO
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 1:205 CHARLEMAGNE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2906
Mailing Address - Country:US
Mailing Address - Phone:770-298-6117
Mailing Address - Fax:770-298-6117
Practice Address - Street 1:4866 BIG ISLAND DR UNIT 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-5301
Practice Address - Country:US
Practice Address - Phone:904-652-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant