MEDICARE: DR. DEBORAH LANE GHANDOUR PA-C, DHSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA9101774	FL

General Provider Information

NPI Number	:	1053329599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBORAH LANE GHANDOUR PA-C, DHSC

Provider Business Mailing Address
First Line	:	1825 3RD ST N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4840
Country	:	US
Telephone Number	:	904-595-5826
Fax Number	:	904-595-5827

Provider Business Practice Location Address
First Line	:	1825 3RD ST N STE B
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4840
Country	:	US
Telephone Number	:	904-595-5826
Fax Number	:	904-595-5827

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	12/16/2022

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