Healthcare Provider Details

I. General information

NPI: 1063435600
Provider Name (Legal Business Name): ELIZABETH J. KEANE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W 8TH ST
JACKSONVILLE FL
32209-6533
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-1022
  • Fax: 904-244-9493
Mailing address:
  • Phone: 904-383-1022
  • Fax: 904-244-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106645
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2050
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: