Provider Demographics
NPI:1295204352
Name:DUQUETTE, MCKENNA (PA)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:DUQUETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13670 WALSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3532
Mailing Address - Country:US
Mailing Address - Phone:727-593-9848
Mailing Address - Fax:727-596-4532
Practice Address - Street 1:13670 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-593-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111736363AM0700X
FL9111736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101501800Medicaid