Provider Demographics
NPI:1700985819
Name:SAMPLE FLYNN, DEANNA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:RAE
Last Name:SAMPLE FLYNN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:RAE
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2461 NE 14TH STREET CSWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-8229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 N HIATUS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5207
Practice Address - Country:US
Practice Address - Phone:954-392-7157
Practice Address - Fax:954-443-4941
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical