Provider Demographics
NPI:1750363271
Name:CHEATHAM, TROY A (PA-C)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:A
Last Name:CHEATHAM
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 1:10131 FOREST HILL BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6109
Mailing Address - Country:US
Mailing Address - Phone:561-798-6600
Mailing Address - Fax:561-615-1958
Practice Address - Street 1:440 N STATE ROAD 7
Practice Address - Street 2:SUITE 103
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3514
Practice Address - Country:US
Practice Address - Phone:561-798-6600
Practice Address - Fax:561-615-1958
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2934363A00000X, 363AM0700X
FLPA0002934363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290228100Medicaid
FL290228100Medicaid
FLE2925ZMedicare ID - Type Unspecified