Provider Demographics
NPI:1346815198
Name:TELLEZ, KATRINA (PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4989
Mailing Address - Country:US
Mailing Address - Phone:407-846-0090
Mailing Address - Fax:
Practice Address - Street 1:720 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4989
Practice Address - Country:US
Practice Address - Phone:407-846-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-07-28
Deactivation Date:2021-07-02
Deactivation Code:
Reactivation Date:2021-07-26
Provider Licenses
StateLicense IDTaxonomies
FLPA9114318208G00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty