Provider Demographics
NPI:1164446290
Name:RODRIGUEZ, RAIZA (PA-C)
Entity type:Individual
Prefix:
First Name:RAIZA
Middle Name:
Last Name:RODRIGUEZ
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:2392 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3310
Practice Address - Country:US
Practice Address - Phone:772-223-5606
Practice Address - Fax:772-223-4949
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0786Medicare PIN
P90856Medicare UPIN