Provider Demographics
NPI:1730179599
Name:VELEZ, ERICK GLENN (PA-C)
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:GLENN
Last Name:VELEZ
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 1:1890 STATE ROAD 436
Mailing Address - Street 2:SUITE 255
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-2285
Mailing Address - Country:US
Mailing Address - Phone:407-657-7900
Mailing Address - Fax:407-657-7942
Practice Address - Street 1:1890 STATE ROAD 436
Practice Address - Street 2:SUITE 255
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2285
Practice Address - Country:US
Practice Address - Phone:407-657-7900
Practice Address - Fax:407-657-7942
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291422100Medicaid
FL291422100Medicaid
FLS64658Medicare UPIN