Provider Demographics
NPI:1063092096
Name:PATSIOURA, THEODORA
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:PATSIOURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 W MISSISSIPPI AVE UNIT 8
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6100
Mailing Address - Country:US
Mailing Address - Phone:601-810-5807
Mailing Address - Fax:
Practice Address - Street 1:4270 LAKE IN THE WOODS DR
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34607-2501
Practice Address - Country:US
Practice Address - Phone:352-597-7249
Practice Address - Fax:352-597-9523
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant