Provider Demographics
NPI:1710166673
Name:FALLON, ELIZABETH CECE (PAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CECE
Last Name:FALLON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 BAYSHORE BLVD
Mailing Address - Street 2:HEPATOLOGY
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2707
Mailing Address - Country:US
Mailing Address - Phone:813-844-5659
Mailing Address - Fax:813-844-1990
Practice Address - Street 1:409 BAYSHORE BLVD
Practice Address - Street 2:HEPATOLOGY
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2707
Practice Address - Country:US
Practice Address - Phone:813-844-5659
Practice Address - Fax:813-844-1990
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004603100Medicaid
FL004603100Medicaid