Provider Demographics
NPI:1184157968
Name:CREMATA, KATIE WEISZ (PA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:WEISZ
Last Name:CREMATA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:WEISZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4800 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3635 CLYDE MORRIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-2349
Practice Address - Country:US
Practice Address - Phone:386-788-7842
Practice Address - Fax:386-756-8802
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020626200Medicaid