Provider Demographics
NPI:1821196924
Name:ANDRE, LATRESE S (PAC)
Entity type:Individual
Prefix:MS
First Name:LATRESE
Middle Name:S
Last Name:ANDRE
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:LATRESE
Other - Middle Name:S
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1824 KING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-384-3343
Mailing Address - Fax:
Practice Address - Street 1:1000 RIVERSIDE AVE STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4154
Practice Address - Country:US
Practice Address - Phone:904-388-7521
Practice Address - Fax:904-388-3541
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA100931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
E3620ZMedicare ID - Type Unspecified