Provider Demographics
NPI:1750790150
Name:DORTA, CRISTINA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:MARIE
Last Name:DORTA
Suffix:
Gender:F
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 1:2753 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6699
Mailing Address - Country:US
Mailing Address - Phone:352-404-7570
Mailing Address - Fax:
Practice Address - Street 1:2753 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6699
Practice Address - Country:US
Practice Address - Phone:352-404-7570
Practice Address - Fax:352-404-7573
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107935363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013193000Medicaid