Provider Demographics
NPI:1306447420
Name:FUENTES, ALISSA KAY (PA-C)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:KAY
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:KAY
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8317 BERMUDA SOUND WAY
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-1729
Mailing Address - Country:US
Mailing Address - Phone:786-589-2361
Mailing Address - Fax:
Practice Address - Street 1:6169 S JOG RD STE B3
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6514
Practice Address - Country:US
Practice Address - Phone:561-433-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant