MEDICARE: MR. JODY VICENCIO CRISOSTOMO PAC

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	PA1911	FL

General Provider Information

NPI Number	:	1700829033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JODY VICENCIO CRISOSTOMO PAC

Provider Business Mailing Address
First Line	:	PO BOX 57970
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32241-7970
Country	:	US
Telephone Number	:	904-737-1838
Fax Number	:

Provider Business Practice Location Address
First Line	:	4243 SUNBEAM RD STE 6
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-8975
Country	:	US
Telephone Number	:	904-737-1838
Fax Number	:	904-737-1206

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	04/11/2008

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