Provider Demographics
NPI:1922178706
Name:TAKIS, CAROL L (PA C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:TAKIS
Suffix:
Gender:F
Credentials:PA C
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 121009
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34712
Mailing Address - Country:US
Mailing Address - Phone:352-394-4035
Mailing Address - Fax:352-241-0896
Practice Address - Street 1:1135 LAKE AVE
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-394-4035
Practice Address - Fax:352-241-0896
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103292207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q48396Medicare UPIN
FLU5187AMedicare ID - Type Unspecified