Provider Demographics
NPI:1205858719
Name:FARDETTE, PETRINE (PA C)
Entity Type:Individual
Prefix:
First Name:PETRINE
Middle Name:
Last Name:FARDETTE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:PETRINE
Other - Middle Name:
Other - Last Name:HINRICHSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1772
Mailing Address - Country:US
Mailing Address - Phone:954-567-1332
Mailing Address - Fax:954-537-7705
Practice Address - Street 1:3000 BAYVIEW DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1772
Practice Address - Country:US
Practice Address - Phone:954-567-1332
Practice Address - Fax:954-537-7705
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044395363A00000X
FLPA3368363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290935900Medicaid
S86995Medicare UPIN