Provider Demographics
NPI:1366466724
Name:HALVORSEN, CHRISTINE M (PAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:HALVORSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E DIXIE AVE
Mailing Address - Street 2:PLAZA 901
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5953
Mailing Address - Country:US
Mailing Address - Phone:352-728-2404
Mailing Address - Fax:352-787-7401
Practice Address - Street 1:601 E DIXIE AVE
Practice Address - Street 2:PLAZA 901
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5953
Practice Address - Country:US
Practice Address - Phone:352-728-2404
Practice Address - Fax:352-787-7401
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290462400Medicaid
E1791ZMedicare PIN
FL290462400Medicaid