Healthcare Provider Details

I. General information

NPI: 1912927237
Provider Name (Legal Business Name): MARY JOSEPHINE SUTHERLAND P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3189 US HIGHWAY 17
FLEMING ISLAND FL
32003-7109
US

IV. Provider business mailing address

3189 HIGHWAY 17
GREEN COVE SPRINGS FL
32043-9371
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-0247
  • Fax: 904-339-9945
Mailing address:
  • Phone: 904-621-0247
  • Fax: 904-339-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2225
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2225
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: