Provider Demographics
NPI:1336187996
Name:LICATA, PAUL ANTHONY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:LICATA
Suffix:
Gender:M
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 1:8105 NW 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-1441
Mailing Address - Country:US
Mailing Address - Phone:954-724-0276
Mailing Address - Fax:
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-724-0276
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102128363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP82162Medicare UPIN