Provider Demographics
NPI:1689657066
Name:BALLESTEROS, JORGE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:BALLESTEROS
Suffix:
Gender:M
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 1:7824 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8201
Mailing Address - Country:US
Mailing Address - Phone:407-282-2001
Mailing Address - Fax:407-282-2028
Practice Address - Street 1:7824 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8201
Practice Address - Country:US
Practice Address - Phone:407-282-2001
Practice Address - Fax:407-282-2028
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103585363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical