MEDICARE: MR. GREG CLOUD P.A. - C

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	363A00000X	Physician Assistant	PA2193	FL

General Provider Information

NPI Number	:	1275520876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREG CLOUD P.A. - C

Provider Business Mailing Address
First Line	:	3716 UNIVERSITY BLVD S
Second Line	:	SUITE 3
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4355
Country	:	US
Telephone Number	:	904-733-3529
Fax Number	:	904-730-7687

Provider Business Practice Location Address
First Line	:	3716 UNIVERSITY BLVD S
Second Line	:	SUITE 3
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4355
Country	:	US
Telephone Number	:	904-733-3529
Fax Number	:	904-730-7687

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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