Provider Demographics
NPI:1518362722
Name:PAULTRE, VANESSA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MARIE
Last Name:PAULTRE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:VANESSA
Other - Middle Name:MARIE
Other - Last Name:LOZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7782 SW 60TH PL
Mailing Address - Street 2:APT 294
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-4892
Mailing Address - Country:US
Mailing Address - Phone:954-547-9513
Mailing Address - Fax:
Practice Address - Street 1:2000 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1136
Practice Address - Country:US
Practice Address - Phone:352-273-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9108128363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013880800Medicaid
FLIA162ZMedicare PIN