Provider Demographics
NPI:1447483466
Name:SUDDARTH, RACHAEL L (PA)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:L
Last Name:SUDDARTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 MEASE DR STE 404
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-6606
Mailing Address - Country:US
Mailing Address - Phone:727-712-0980
Mailing Address - Fax:813-635-2694
Practice Address - Street 1:1840 MEASE DR STE 404
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6606
Practice Address - Country:US
Practice Address - Phone:727-712-0980
Practice Address - Fax:813-635-2694
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105226363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001535500Medicaid
FLCQ004ZMedicare PIN