Provider Demographics
NPI:1548374770
Name:REPASS, IVAN R (PA-C)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:R
Last Name:REPASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4949
Mailing Address - Country:US
Mailing Address - Phone:407-647-2287
Mailing Address - Fax:407-643-1300
Practice Address - Street 1:701 PLATINUM PT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4871
Practice Address - Country:US
Practice Address - Phone:407-206-4500
Practice Address - Fax:407-829-2563
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1668363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP49635Medicare UPIN
FLE6819ZMedicare ID - Type Unspecified