Provider Demographics
NPI:1972610020
Name:CIMILLUCA, CARA C (PA-C)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:C
Last Name:CIMILLUCA
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 1:625 6TH AVE S
Mailing Address - Street 2:SUITE 450
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4629
Mailing Address - Country:US
Mailing Address - Phone:727-898-2663
Mailing Address - Fax:727-586-6836
Practice Address - Street 1:625 6TH AVE S
Practice Address - Street 2:SUITE 450
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4629
Practice Address - Country:US
Practice Address - Phone:727-898-2663
Practice Address - Fax:727-586-6836
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104283363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N7446OtherBLUE SHILD
FL292828100Medicaid