Healthcare Provider Details

I. General information

NPI: 1720060833
Provider Name (Legal Business Name): MARYKATE H VELLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 W NEWBERRY RD EAST WING, SUITE 100
GAINESVILLE FL
32605-4308
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-332-3900
  • Fax: 352-332-5009
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2618
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2618
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: