Healthcare Provider Details

I. General information

NPI: 1184157968
Provider Name (Legal Business Name): KATIE WEISZ CREMATA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE LYNN WEISZ

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 CLYDE MORRIS BLVD STE 100
PORT ORANGE FL
32129-2349
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-7842
  • Fax: 386-756-8802
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9110239
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: