Provider Demographics
NPI:1558439836
Name:RACHELLI, DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:RACHELLI
Suffix:
Gender:M
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 1:519 WHEATSTONE PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-4450
Mailing Address - Country:US
Mailing Address - Phone:407-432-0729
Mailing Address - Fax:
Practice Address - Street 1:2323 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3059
Practice Address - Country:US
Practice Address - Phone:407-418-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2930749-00Medicaid
FL2930749-00Medicaid
FLAJ494ZMedicare PIN