Provider Demographics
NPI:1639845977
Name:D'ESPOSITO, VICTORIA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANNE
Last Name:D'ESPOSITO
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 1:3520 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7522
Mailing Address - Country:US
Mailing Address - Phone:321-543-9135
Mailing Address - Fax:
Practice Address - Street 1:340 NW COMMERCE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4709
Practice Address - Country:US
Practice Address - Phone:321-543-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9114897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant