Provider Demographics
NPI:1518726116
Name:PETIT FRERE, JONAS
Entity Type:Individual
Prefix:
First Name:JONAS
Middle Name:
Last Name:PETIT FRERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 NW 55TH AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-2537
Mailing Address - Country:US
Mailing Address - Phone:195-447-0505
Mailing Address - Fax:
Practice Address - Street 1:2824 NW 55TH AVE APT 2C
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313-2537
Practice Address - Country:US
Practice Address - Phone:195-447-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1288363AM0700X
AZ10301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical