Healthcare Provider Details

I. General information

NPI: 1982650099
Provider Name (Legal Business Name): LAVERLE VUST PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NW 13TH ST EMERGENCY DEPARTMENT
HOMESTEAD FL
33030-4228
US

IV. Provider business mailing address

PO BOX 863997
ORLANDO FL
32886-3997
US

V. Phone/Fax

Practice location:
  • Phone: 786-243-8000
  • Fax: 904-346-0113
Mailing address:
  • Phone: 866-396-6418
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0002491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: