Provider Demographics
NPI:1578874038
Name:ACOSTA, EVELISSE (MA)
Entity Type:Individual
Prefix:
First Name:EVELISSE
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 W HILLSBOROUGH AVE STE N
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5309
Mailing Address - Country:US
Mailing Address - Phone:813-901-9369
Mailing Address - Fax:813-901-9368
Practice Address - Street 1:5011 W HILLSBOROUGH AVE STE N
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5309
Practice Address - Country:US
Practice Address - Phone:813-901-9369
Practice Address - Fax:813-901-9368
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50300173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine