Provider Demographics
NPI:1699859389
Name:CREVECOEUR, IRLANDE KATHIA (PA)
Entity Type:Individual
Prefix:
First Name:IRLANDE
Middle Name:KATHIA
Last Name:CREVECOEUR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2838
Mailing Address - Country:US
Mailing Address - Phone:954-441-9562
Mailing Address - Fax:
Practice Address - Street 1:1240 NW 119TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167-3232
Practice Address - Country:US
Practice Address - Phone:305-685-5688
Practice Address - Fax:305-687-1817
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5124Medicare ID - Type Unspecified
FLQ47898Medicare UPIN