Healthcare Provider Details

I. General information

NPI: 1467928598
Provider Name (Legal Business Name): KEVIN JOSEPH VACCARELLO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10251 W COMMERCIAL BLVD
SUNRISE FL
33351-4326
US

IV. Provider business mailing address

10251 W COMMERCIAL BLVD
SUNRISE FL
33351-4326
US

V. Phone/Fax

Practice location:
  • Phone: 954-580-4100
  • Fax:
Mailing address:
  • Phone: 954-580-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111495
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: