Provider Demographics
NPI:1568509164
Name:DE LA ROCHA, JOSE JULIAN (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JULIAN
Last Name:DE LA ROCHA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9124 EGRET COVE CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3113
Mailing Address - Country:US
Mailing Address - Phone:813-416-5673
Mailing Address - Fax:
Practice Address - Street 1:13111 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7401
Practice Address - Country:US
Practice Address - Phone:813-671-0064
Practice Address - Fax:813-672-2153
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS26554Medicare UPIN