MEDICARE: MR. JOSE LUIS LIZARDI PA-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	363AM0700X	Medical Physician Assistant	PA3731	FL

General Provider Information

NPI Number	:	1710959622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE LUIS LIZARDI PA-C

Provider Business Mailing Address
First Line	:	PO BOX 44008
Second Line	:	UFJP WINTER HAVEN
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4008
Country	:	US
Telephone Number	:	904-244-3199
Fax Number	:	904-244-3425

Provider Business Practice Location Address
First Line	:	2330 NORTH BLVD W
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8989
Country	:	US
Telephone Number	:	407-931-0444
Fax Number	:	407-962-4446

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	01/17/2025

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