Provider Demographics
NPI:1013133826
Name:PACK, VITIA ANGELA (PA-C)
Entity Type:Individual
Prefix:
First Name:VITIA
Middle Name:ANGELA
Last Name:PACK
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 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2000
Mailing Address - Fax:786-515-9308
Practice Address - Street 1:17160 ROYAL PALM BLVD STE 2
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2395
Practice Address - Country:US
Practice Address - Phone:954-762-6440
Practice Address - Fax:800-618-2120
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106235363A00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA31540OtherLICENSE NUMBER