Provider Demographics
NPI:1922082148
Name:KRACKOV, RACHEL E (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:E
Last Name:KRACKOV
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:E
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:15400 BISCAYNE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4614
Mailing Address - Country:US
Mailing Address - Phone:305-957-7277
Mailing Address - Fax:305-957-7048
Practice Address - Street 1:15400 BISCAYNE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-4614
Practice Address - Country:US
Practice Address - Phone:305-957-7277
Practice Address - Fax:305-957-7048
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00273363A00000X
FL9104539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7050011Medicaid
RI7050011Medicaid
RIP97386Medicare UPIN