Healthcare Provider Details

I. General information

NPI: 1831676584
Provider Name (Legal Business Name): LUKAS SCOTT HAYDEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax:
Mailing address:
  • Phone: 904-697-4600
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberPA9111383
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: