Provider Demographics
NPI:1851486609
Name:PREVATT, HARRY R (PA)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:R
Last Name:PREVATT
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:PO BOX 863639
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3639
Mailing Address - Country:US
Mailing Address - Phone:904-827-0507
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:400 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-826-4700
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0002707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS79133Medicare UPIN
FLE2464ZMedicare ID - Type Unspecified