Provider Demographics
NPI:1295708568
Name:GREGG, ANNE C (PA)
Entity type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:C
Last Name:GREGG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:C
Other - Last Name:MALLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 S HARBOR CITY BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5591
Mailing Address - Country:US
Mailing Address - Phone:321-723-7716
Mailing Address - Fax:321-723-0604
Practice Address - Street 1:2222 S HARBOR CITY BLVD STE 610
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5591
Practice Address - Country:US
Practice Address - Phone:321-723-7716
Practice Address - Fax:321-723-0604
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292656301Medicaid
FLOU843OtherMEDICARE HF
FLU4324YMedicare PIN