Provider Demographics
NPI:1821395195
Name:SUMMERS, JULIET ALEENE (PAC)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:ALEENE
Last Name:SUMMERS
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 1:12880 COMMODITY PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3101
Mailing Address - Country:US
Mailing Address - Phone:813-343-5500
Mailing Address - Fax:813-343-5506
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:813-343-5500
Practice Address - Fax:813-353-5506
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004244300Medicaid