Provider Demographics
NPI:1225213200
Name:SEVILLA-BALLEREAU, AUDREY C (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:C
Last Name:SEVILLA-BALLEREAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:C
Other - Last Name:SEVILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:MAB 2ND FLOOR
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-321-6580
Mailing Address - Fax:
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:2ND MAB
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-321-6580
Practice Address - Fax:813-443-8135
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108569363A00000X, 363AS0400X
GUPA-070363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014813700Medicaid