Provider Demographics
NPI:1659996361
Name:DELAGE, PATRICK LEE (PA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LEE
Last Name:DELAGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-4615
Mailing Address - Country:US
Mailing Address - Phone:520-869-9718
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-4615
Practice Address - Country:US
Practice Address - Phone:352-265-5911
Practice Address - Fax:352-265-5606
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9113315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program