Provider Demographics
NPI:1366185241
Name:PEDRAZA, SERGIO ENRIQUE
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:ENRIQUE
Last Name:PEDRAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14214 PONDHAWK LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-3207
Mailing Address - Country:US
Mailing Address - Phone:813-863-6737
Mailing Address - Fax:
Practice Address - Street 1:801 W BAY DR STE 605
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3268
Practice Address - Country:US
Practice Address - Phone:727-489-3305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2021096609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty