Provider Demographics
NPI:1912191016
Name:HALL, RAETTE DAWN (PA)
Entity Type:Individual
Prefix:
First Name:RAETTE
Middle Name:DAWN
Last Name:HALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RAETTE
Other - Middle Name:DAWN
Other - Last Name:MOODIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5312 SILVER LEAF LN
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3204
Mailing Address - Country:US
Mailing Address - Phone:941-504-7722
Mailing Address - Fax:
Practice Address - Street 1:2830 BEE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-7115
Practice Address - Country:US
Practice Address - Phone:941-927-1234
Practice Address - Fax:941-921-0043
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104287363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292881700Medicaid
FLAF283ZMedicare PIN