Healthcare Provider Details

I. General information

NPI: 1124171384
Provider Name (Legal Business Name): GUERDA ETIENNE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 S LAKE ST
LEESBURG FL
34748-5934
US

IV. Provider business mailing address

1109 SW 10TH ST
OCALA FL
34474-2725
US

V. Phone/Fax

Practice location:
  • Phone: 352-314-9300
  • Fax: 352-314-9212
Mailing address:
  • Phone: 352-629-3455
  • Fax: 352-629-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: