Provider Demographics
NPI:1184621856
Name:COUVILLON, MICHAEL ANDRE (NP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDRE
Last Name:COUVILLON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 ZEMKE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-5023
Mailing Address - Country:US
Mailing Address - Phone:813-827-4410
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN045162 - AP03387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00130594OtherRR MEDICARE
LA1564907Medicaid
LA5X8736833Medicare PIN
LAP00130594OtherRR MEDICARE
LAS81645Medicare UPIN