Provider Demographics
NPI:1477599124
Name:VIDAL, KAREN L (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:VIDAL
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 1:946 SE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-3910
Mailing Address - Country:US
Mailing Address - Phone:352-427-1326
Mailing Address - Fax:
Practice Address - Street 1:29253 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-2102
Practice Address - Country:US
Practice Address - Phone:727-313-4764
Practice Address - Fax:727-313-4764
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2828363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1096TOtherQSS SCS PTAN
FL2927853 00Medicaid
FLP00108704OtherMEDICARE RR
FLE1096TOtherQSS SCS PTAN
FL2927853 00Medicaid
FLS60623Medicare UPIN
FLE1096VMedicare PIN
FLE1096WMedicare PIN