Provider Demographics
NPI:1497057350
Name:DUQUE, JOHANA F (PA)
Entity Type:Individual
Prefix:
First Name:JOHANA
Middle Name:F
Last Name:DUQUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 W OAKLAND PARK BLVD
Mailing Address - Street 2:201
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7260
Mailing Address - Country:US
Mailing Address - Phone:954-735-3535
Mailing Address - Fax:954-735-7908
Practice Address - Street 1:4850 W OAKLAND PARK BLVD
Practice Address - Street 2:201
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7260
Practice Address - Country:US
Practice Address - Phone:954-735-3535
Practice Address - Fax:954-735-7908
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105593363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009196800Medicaid
FL009196800Medicaid