Provider Demographics
NPI:1578587937
Name:SALLUSTIO, JUDITH E (PAC)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:E
Last Name:SALLUSTIO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ETUE
Other - Last Name:SALLISTIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1601 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1135
Mailing Address - Country:US
Mailing Address - Phone:352-376-1611
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:352-379-4048
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290970700Medicaid
P29380Medicare UPIN
FL290970700Medicaid