Provider Demographics
NPI:1861429094
Name:PERREIRA, RANDALL (PAC)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:
Last Name:PERREIRA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7544 JACQUE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-697-2200
Mailing Address - Fax:727-863-8774
Practice Address - Street 1:7544 JACQUE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-697-2200
Practice Address - Fax:727-863-8774
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0001786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290641400Medicaid
FL290641400Medicaid
FL0613080001Medicare NSC
FL970008077Medicare PIN
FLS66631Medicare UPIN