MEDICARE: IRLANDE KATHIA CREVECOEUR P.A.

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	PA9101753	FL

General Provider Information

NPI Number	:	1699859389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRLANDE KATHIA CREVECOEUR P.A.

Provider Business Mailing Address
First Line	:	8203 WINDSOR DR
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-2838
Country	:	US
Telephone Number	:	954-441-9562
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 NW 119TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33167-3232
Country	:	US
Telephone Number	:	305-685-5688
Fax Number	:	305-687-1817

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	07/08/2007

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