Provider Demographics
NPI:1184664583
Name:LODGE, PATTY J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:PATTY
Middle Name:J
Last Name:LODGE
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 1:755 RINEHART RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4874
Mailing Address - Country:US
Mailing Address - Phone:407-333-1550
Mailing Address - Fax:407-333-3081
Practice Address - Street 1:755 RINEHART RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4874
Practice Address - Country:US
Practice Address - Phone:407-333-1550
Practice Address - Fax:407-333-3081
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1939363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical