Provider Demographics
NPI:1912194713
Name:ACOSTA, LILLIAN (PA)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 NW 88TH TERR
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33024
Mailing Address - Country:US
Mailing Address - Phone:954-533-3650
Mailing Address - Fax:
Practice Address - Street 1:703 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1006
Practice Address - Country:US
Practice Address - Phone:954-844-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ13507Medicare UPIN
GA97WCGKQMedicare PIN