Provider Demographics
NPI:1245281153
Name:ZEVIN, DEZBAH A (PAC)
Entity type:Individual
Prefix:
First Name:DEZBAH
Middle Name:A
Last Name:ZEVIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19649 LONG LAKE RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5494
Mailing Address - Country:US
Mailing Address - Phone:813-957-1654
Mailing Address - Fax:813-333-7445
Practice Address - Street 1:13020 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0925
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6186
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1234Medicaid
FLY02TCOtherBC/BS
FL005978000Medicaid
FL1234Medicaid