Healthcare Provider Details

I. General information

NPI: 1285276139
Provider Name (Legal Business Name): EVONNA ACKOUREY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 WALDEMERE ST STE 504
SARASOTA FL
34239-2941
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-8525
  • Fax: 941-917-8526
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061187
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: