Provider Demographics
NPI:1346750239
Name:FLACK, RACHEL MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:MARIE
Last Name:FLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3001 W DR MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:813-554-8527
Mailing Address - Fax:813-554-8496
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4619
Practice Address - Fax:813-554-8496
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110663363AS0400X
FLPA9110663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022800900Medicaid