Provider Demographics
NPI:1629028287
Name:PREVILON, JOSEPHINE A (PAC)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:A
Last Name:PREVILON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:
Other - Last Name:CADET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:
Practice Address - Street 1:603 N FLAMINGO RD STE 151
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1021
Practice Address - Country:US
Practice Address - Phone:954-265-4325
Practice Address - Fax:954-436-4606
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292155300Medicaid
Q42260Medicare UPIN