Provider Demographics
NPI:1457781072
Name:TSE, FANNY (PA-C)
Entity Type:Individual
Prefix:
First Name:FANNY
Middle Name:
Last Name:TSE
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 1:829 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-1448
Mailing Address - Country:US
Mailing Address - Phone:954-993-7084
Mailing Address - Fax:
Practice Address - Street 1:21150 BISCAYNE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1231
Practice Address - Country:US
Practice Address - Phone:954-482-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant