MEDICARE: PETRINE FARDETTE PA C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	ME0044395	FL
2	363AS0400X	Surgical Physician Assistant	PA3368	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205858719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETRINE FARDETTE PA C

Provider Business Mailing Address
First Line	:	3000 BAYVIEW DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1772
Country	:	US
Telephone Number	:	954-567-1332
Fax Number	:	954-537-7705

Provider Business Practice Location Address
First Line	:	3000 BAYVIEW DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1772
Country	:	US
Telephone Number	:	954-567-1332
Fax Number	:	954-537-7705

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	10/08/2019

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Directions to “ PETRINE FARDETTE PA C” Practice Location

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