=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154307353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUARTE VELOSA PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2005
-----------------------------------------------------
Last Update Date | 11/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E DIXIE AVE EMERGENCY DEPARTMENT
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-425-1565
-----------------------------------------------------
Fax | 919-425-0478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3114 CROASDAILE DR SUITE 200
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27705-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-425-1565
-----------------------------------------------------
Fax | 919-425-0478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 9103207
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9103207
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------