Healthcare Provider Details

I. General information

NPI: 1154083533
Provider Name (Legal Business Name): CHRIS LE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 US HIGHWAY 17 STE 200
FLEMING ISLAND FL
32003-4823
US

IV. Provider business mailing address

6800 SOUTPOINT PKWY STE 300
JACKSONVILLE FL
32216
US

V. Phone/Fax

Practice location:
  • Phone: 904-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 904-634-0640
  • Fax: 904-634-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114922
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: