Provider Demographics
NPI:1831118595
Name:RICKARDS, CLEVELAND ABBE (PA)
Entity Type:Individual
Prefix:MR
First Name:CLEVELAND
Middle Name:ABBE
Last Name:RICKARDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 58TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-4675
Mailing Address - Country:US
Mailing Address - Phone:772-257-3200
Mailing Address - Fax:772-257-0187
Practice Address - Street 1:1820 58TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32966-4675
Practice Address - Country:US
Practice Address - Phone:772-257-3200
Practice Address - Fax:772-257-0187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT55-0030638363A00000X
FLPA9112293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000156Medicaid
VTAP1937Medicare ID - Type Unspecified
VT9000156Medicaid