Provider Demographics
NPI:1841911443
Name:DUQUE, KATIE MICHELLE
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:MICHELLE
Last Name:DUQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:MICHELLE
Other - Last Name:PASTRANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:89 W COPELAND DR FL 2
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2002
Mailing Address - Country:US
Mailing Address - Phone:321-841-7550
Mailing Address - Fax:321-841-8185
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-841-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
FLPA9116510363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty