MEDICARE: MRS. CYNTHIA MCKEON PHYSICIAN ASSISTANT

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	PA9100890	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA9100890	OTHER	FL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1942240924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CYNTHIA MCKEON PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	2900 W MIDWAY RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-4955
Country	:	US
Telephone Number	:	772-467-0961
Fax Number	:	772-467-6683

Provider Business Practice Location Address
First Line	:	2900 W MIDWAY RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-4955
Country	:	US
Telephone Number	:	772-467-0961
Fax Number	:	772-467-6683

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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