Provider Demographics
NPI:1679594527
Name:ESTELLE, STORM A (PA-C)
Entity Type:Individual
Prefix:
First Name:STORM
Middle Name:A
Last Name:ESTELLE
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 1:3255 NW 94TH AVE UNIT 8154
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075-2009
Mailing Address - Country:US
Mailing Address - Phone:954-854-0628
Mailing Address - Fax:
Practice Address - Street 1:7201 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2913
Practice Address - Country:US
Practice Address - Phone:954-854-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102746363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0327ZMedicare ID - Type Unspecified
FLP83621Medicare UPIN