Provider Demographics
NPI:1285276139
Name:ACKOUREY, EVONNA (PA-C)
Entity type:Individual
Prefix:
First Name:EVONNA
Middle Name:
Last Name:ACKOUREY
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:PO BOX 947407
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST STE 504
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2941
Practice Address - Country:US
Practice Address - Phone:941-917-8525
Practice Address - Fax:941-917-8526
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA061187363A00000X
FLPA9117342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant