Healthcare Provider Details

I. General information

NPI: 1063136257
Provider Name (Legal Business Name): IRISELIS CRUZADO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 BAHIA VISTA ST STE 204
SARASOTA FL
34239-2625
US

IV. Provider business mailing address

11305 MAYBROOK AVE
RIVERVIEW FL
33569-5951
US

V. Phone/Fax

Practice location:
  • Phone: 941-202-1999
  • Fax: 941-202-2009
Mailing address:
  • Phone: 407-754-6325
  • Fax: 941-202-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116565
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: