Provider Demographics
NPI:1992989768
Name:LEVY, ETHAN TADD (PA-C)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:TADD
Last Name:LEVY
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 1:175 2ND ST S
Mailing Address - Street 2:# 1007
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4314
Mailing Address - Country:US
Mailing Address - Phone:352-514-3270
Mailing Address - Fax:
Practice Address - Street 1:3001 N ROCKY POINT DR E
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5810
Practice Address - Country:US
Practice Address - Phone:813-289-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103772363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical