Healthcare Provider Details

I. General information

NPI: 1760887210
Provider Name (Legal Business Name): MICHAEL JARETH SWANSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD SUITE 204
FORT PIERCE FL
34950-4838
US

IV. Provider business mailing address

2402 FRIST BLVD SUITE 204
FORT PIERCE FL
34950-4838
US

V. Phone/Fax

Practice location:
  • Phone: 772-462-3939
  • Fax: 772-462-3938
Mailing address:
  • Phone: 772-462-3939
  • Fax: 772-462-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9108363
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: