Provider Demographics
NPI:1679939185
Name:CABALLERO, CARLOS (PA-C)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CABALLERO
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1921 WALDEMERE ST STE 310
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-917-5400
Practice Address - Fax:941-917-5420
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9109229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB7E7NOtherBCBS
FL4038126OtherAETNA
FL398574OtherAVMED
FLP972734OtherOPTIMUM
FLP01619306OtherRR MEDICARE
FL7231569OtherCIGNA
FLP1037507OtherFREEDOM
FLP972734OtherOPTIMUM