Provider Demographics
NPI:1386042646
Name:SEREDA, ROMAN (PA)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:SEREDA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 48TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18167 US HIGHWAY 19 N
Practice Address - Street 2:SUITE 650
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-3528
Practice Address - Country:US
Practice Address - Phone:800-507-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLPA9108442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant