Provider Demographics
NPI:1154892610
Name:GANESH, DEVINA VIDYA (PA-C)
Entity type:Individual
Prefix:
First Name:DEVINA
Middle Name:VIDYA
Last Name:GANESH
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 1:1982 HAMMOCK MOSS DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32820-2231
Mailing Address - Country:US
Mailing Address - Phone:407-790-2607
Mailing Address - Fax:
Practice Address - Street 1:13800 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7401
Practice Address - Country:US
Practice Address - Phone:407-631-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant