Provider Demographics
NPI:1629485909
Name:BURCHENSON, KRYSTA-GAYE LATOYA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRYSTA-GAYE
Middle Name:LATOYA
Last Name:BURCHENSON
Suffix:
Gender:F
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 1:3403 FOXCROFT RD
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4186
Mailing Address - Country:US
Mailing Address - Phone:954-445-7871
Mailing Address - Fax:
Practice Address - Street 1:1515 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1134
Practice Address - Country:US
Practice Address - Phone:352-265-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108009363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012891300Medicaid
FLHY098ZMedicare PIN